nlbarnes
Expert
Hello - provider performed 21501 on 05/16/24. The pt comes back on 07/09/24, within the 90-day global period. Pathology from 05/16/24 revealed residue of RT parapharyngeal mass. Prior pathology showing atypical squamous cells noted.
First, would I assign the ICD-10 code D37.05 Neoplasm of uncertain behavior of pharynx for both DOS?
Next, provider has submitted and E/M for 07/09/24 to discuss & decision for resection of RT pharyngeal mass and tonsillectomy (this was decided intraoperatively) which was performed on 07/12/24. Is the E/M billable or is it a pre-op visit?
Any sources regarding this scenario would be greatly appreciated.
ASSESSMENT AND PLAN:
The patient was informed about the right pharyngeal mass. She was also informed about our planned surgical intervention under anesthesia in the form of resection of that right pharyngeal mass with direct closure using advancement flap.
The risks involved with surgery, potential complications, alternatives as well as the benefits of the surgery and the option of not performing surgery were discussed in detail again with the patient.
The patient understands the above well, all her questions were answered, and she wishes to proceed with surgery.
Postop instructions, advice for care, medications and return visits were all provided.
First, would I assign the ICD-10 code D37.05 Neoplasm of uncertain behavior of pharynx for both DOS?
Next, provider has submitted and E/M for 07/09/24 to discuss & decision for resection of RT pharyngeal mass and tonsillectomy (this was decided intraoperatively) which was performed on 07/12/24. Is the E/M billable or is it a pre-op visit?
Any sources regarding this scenario would be greatly appreciated.
ASSESSMENT AND PLAN:
The patient was informed about the right pharyngeal mass. She was also informed about our planned surgical intervention under anesthesia in the form of resection of that right pharyngeal mass with direct closure using advancement flap.
The risks involved with surgery, potential complications, alternatives as well as the benefits of the surgery and the option of not performing surgery were discussed in detail again with the patient.
The patient understands the above well, all her questions were answered, and she wishes to proceed with surgery.
Postop instructions, advice for care, medications and return visits were all provided.