Documentation supports a simple repair, but a higher-paying interme…

Question

Documentation supports a simple repair, but a higher-paying intermediate repair CPT is financially attractive. What ethical CPT selection rule applies?

Accepted Answer

Select the CPT that matches the documented work, not a higher-paying near-cousin code. — Close cousins in the CPT book can look alike until you read the note. If the work was a simple repair, you don't 'upgrade' to the richer code just because it pays more—match the story on the page.

Answer

Always choose the highest-RVU code in the anatomic family when documentation is ambiguous and unanswered.

Answer

Bill both simple and intermediate repair codes for the same closure to capture both fees.

Answer

Use the intermediate code whenever the charge master defaults to it, regardless of the note.

Documentation supports a simple repair, but a higher-paying intermediate repair CPT is financially attractive. What ethical CPT selection rule applies?

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