General Surgery Coding Alert

Question: A new patient presented with apparently infected sores on lower back and abdomen for possible treatment. Our surgeon performed an expanded problem focused history and exam and submitted a smear from the wound site for lab examination. The report documents a cutaneous abscess of abdominal wall and back with “Staphylococcus aureus” as the underlying cause. How should we code this?

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Answer: Bill the E/M service as 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making).

The diagnosis coding is a little more difficult, because it requires multiple codes.

Report the abscesses as L02.211 (Cutaneous abscess of abdominal wall) and L02.212 (Cutaneous abscess of back [any part, except buttock]).

For the documented underlying infection, you should list B95.61 (Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere).

Explanation: If you have documentation of an infectious agent causing the abscess, you need to include a code from B95 through B97 as a secondary diagnosis.