I&D vs. Excision

I&D vs. Excision

By Brenda Edwards, CPC,CPB, CPMA, CPC-I, CEMC, CRC

To code an excision, or an incision and drainage (I&D)? That seems to be an age-old question.

Examination of the suspected problem could identify an abscess, cyst, hematoma or seroma. Understanding the differences in these fluid filled pockets is imperative to code accurately. An abscess is filled with pus and is usually left to drain. A cyst is removed along with the epithelial lining (capsule). A hematoma is a collection of blood outside of a blood vessel. A seroma is a collection of serum in the body which produces a tumor like mass.

The key in determining the correct code for the removal of any of these problems lies in the documentation of the procedure performed. Things to consider:

• Did the provider mix terms of the procedure performed?

o A complete excision of a cyst was performed by incision and drainage

• Was tissue excised?

o Does documentation indicate the capsule and cyst were removed in its entirety?

• Was a simple or complex procedure performed?

o Was an incision left open to drain?

o Was a drain tube left in place?

o Was there a primary closure and/or Z-plasty?

Don’t limit yourself to the code choices in the Integumentary Section of CPT®. You may find the procedure is more precisely reported with a code found in another section of CPT® such as eye, ear, or genitourinary.

Although we want to report the most accurate code for the procedure performed, another consideration is the impact lost revenue could have, over time. This could occur when a lesser reimbursed procedure is used because the documentation did not clearly indicate the procedure performed, and communication with the provider did not occur to verify what was done.

Communication between the provider and coder is imperative. Providers do not document as we find things in the coding books. An example of this is a resident who asked about coding an “excisional shave biopsy.” I told the resident that only an excision, or a shave, or a biopsy could be coded, but not all of them as one procedure. I was informed that was the way she was taught in medical school. That was an eye opening moment for me—one that led me to ask questions to help narrow down what procedure is actually performed.

Remember, providers look at the clinical perspective and not necessarily the proper coding guidelines. Clear and concise documentation, which may be discovered through communication with the provider, will not only support the service performed but also the quality of care, reimbursement and medical necessity.

dec-clearance-sale

Brenda Edwards

Brenda Edwards

Senior Managing Consultant of Risk Adjustment at Medical Revenue Solutions
Brenda has over 25 years’ experience and is employed with Medical Revenue Solutions. Her experience includes chart auditing, coding and compliance education, and has written many articles for national publications including Healthcare Business Monthly, American Academy of Family Physicians (AAFP) and BC Advantage.Her humorous and engaging presentation style has made her a conference favorite at both national and regional conferences for AAPC as well as local chapter meetings across the country.Brenda is a Certified Professional Coding Instructor (CPC-I), AAPC ICD10-CM/PCS Training Expert, and an AAPC workshop presenter. She served on the AAPC Chapter Association board of directors from 2010-2014 and held office as chair.
Brenda Edwards

Latest posts by Brenda Edwards (see all)

About Has 17 Posts

Brenda has over 25 years’ experience and is employed with Medical Revenue Solutions. Her experience includes chart auditing, coding and compliance education, and has written many articles for national publications including Healthcare Business Monthly, American Academy of Family Physicians (AAFP) and BC Advantage. Her humorous and engaging presentation style has made her a conference favorite at both national and regional conferences for AAPC as well as local chapter meetings across the country. Brenda is a Certified Professional Coding Instructor (CPC-I), AAPC ICD10-CM/PCS Training Expert, and an AAPC workshop presenter. She served on the AAPC Chapter Association board of directors from 2010-2014 and held office as chair.

Leave a Reply

Your email address will not be published. Required fields are marked *