Clinical Indicators: Diagnostic Nasal Endoscopy
Clinical Indicator*Note: Separate Procedure by CPT definition means the code should not be reported with other procedures of which it is a part; in this case, therapeutic nasal/…
Clinical Indicators: Nasal Fracture (with or without septal fracture)
Clinical IndicatorHistory (required) Recent nasal trauma with deformity Physical Examination (required) Evidence of nasal septal fracture (with or without concomitant nasal…
Clinical Indicators: Mandibular Fracture
Clinical IndicatorHistory Trauma Malocclusion perceived by patient Trismus Airway patency concerns Physical Examination Evidence of fracture Palpate or visualize deform…
Clinical Indicators: Le Fort Fracture
Clinical IndicatorHistory Trauma, indicate mechanism of injury Clear rhinorrhea Visual problems Malocclusion/dental status Trismus Facial numbness Difficulty with sense…
Clinical Indicators: Neck Dissection
Clinical Indicator*Note: Radical neck dissection performed in conjunction with removal of a primary malignancy is coded with the primary; in some instances a single CPT codes de…
Clinical Indicators: Thyroidectomy
Clinical IndicatorHistory (one or more required) Thyroid mass Family history of thyroid disease History and/or symptoms of hyper or hypothyroidism History of radiation to …
Clinical Indicators: Palatopharyngoplasty for Obstructive Sleep Apnea
Clinical IndicatorHistory (One or more required) Chronic snoring Restless or interrupted sleep Excessive daytime sleepiness Witnessed apneas or gasping during sleep Prese…
Clinical Indicators: Tonsillectomy, Adenoidectomy, Adenotonsillectomy in Childhood
Clinical IndicatorHistory (one or more required)The guideline includes the following statements*: Watchful waiting for recurrent throat infection: Clinicians should recommend…
Clinical Indicators: Parotidectomy
Clinical IndicatorHistory (one or more required) Parotid mass. Chronic parotitis. A neck mass with histologic findings of metastatic parotid tumor. Parotid duct stone. Ma…
Clinical Indicators: Adenoidectomy
Clinical IndicatorHistory (One or more required) Four or greater episodes of recurrent purulent rhinorrhea in prior 12 months in a child <12 years of age. One episode shou…
Clinical Indicators: Tympanoplasty
Clinical IndicatorRarely if ever performed. History (one required) Conductive hearing loss due to TM perforation. Conductive hearing loss due to ossicular continuity or necro…
Clinical Indicators: Stapedectomy/Stapedotomy
Clinical IndicatorHistory (in addition to hearing loss, list all appropriate) Hearing loss - age of onset, duration, progression, and disability. Also see tests. Otosclerosi…
Clinical Indicators: Myringotomy and Tympanostomy Tubes
Clinical IndicatorHistory (One required) Severe acute otitis media (myringotomy). Hearing loss > 30 dB in patient with otitis media with effusion (myringotomy or tube). …
Clinical Indicators: Mastoidectomy
Clinical Indicator*CPT 92540 and 92541 are "add-on" codes, formerly reported with CPT 95920, which has been deleted and replaced with these 2 new codes. In the 2013 final Medica…
Clinical Indicators: Auditory Brainstem Response
Clinical IndicatorHistory (One or more required) Asymmetric hearing loss Unilateral tinnitus Sudden hearing loss Suspected cerebellopontine angle tumor Suspected demyelin…
ASPS29: Avoidance of Opioid Prescriptions for Closure and Reconstruction After Skin Cancer Resection+
Quality MeasureDownload PDFHigh Priority: Yes; Opioid-related MeasureNQF Number: N/APercentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, w…
ASPS28: Continuation of Anticoagulation Therapy in the Office-based Setting for Closure and Reconstruction After Skin Cancer Resection Procedures+
Quality MeasureDownload PDFHigh Priority: Yes; Patient SafetyNQF Number: N/APercentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, on prescr…
ASPS27: Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures+
Quality MeasureDownload PDFHigh Priority: Yes; Appropriate UseNQF Number: N/APercentage of procedures in patients aged 18 and older with a diagnosis of skin cancer who underw…
