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second procedure thru same incision as main procedure

Marianne Posted Mon 13th of May, 2013 17:01:35 PM

A patient comes in for Levator advancement for ptosis both upperlids. Patient had been repaired 7-8 years ago and has a nodule in both eyelids. While performing the levator advancement the surgeon, thru the same incision, identifies and removes the previous suture along with the suture granuloma which is excised. Would this be incidental to the main procedure, or can he bill seperately for the excision of the granuloma? He is billing 67938 with 67904.
THANKS in advance

SuperCoder Answered Wed 15th of May, 2013 04:45:34 AM

I would recommend to use 67938 here. We do have a separate pathology 'suture granuloma'. The same incision concept does not apply here. No Bundling issues also with these codes.

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