For procedures that can be reported in various correct ways, such as bilateral procedures, the best way to code would be to follow your payors’ preferences, according to the report. HIPAA mandates payors and providers give the same codes.
Other coding guidelines exist within the CPT code book, such as rules for how to record a simple closure of a malignant excision compared with an intermediate or complex closure. Improperly following rules could lose money for your surgery center or increase risk of fraud. Such rules can be found in the CPT code book as well as on payor websites and in provider manuals.
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