Follow These Steps for Coding Cellulitis Encounter
Question: An established 8-year-old patient presents with a slight fever and a red, blistered area on the back of their right hand. Two insect bites are purulent and appear infected after the patient has been scratching them for several days. The pediatrician makes a diagnosis of cellulitis due to scratching and infecting the bites, which the patient’s parent believes are from fleas, as their pet dog has been scratching a lot lately, too. Using a small-gauge needle, the pediatrician opens the blistered area and drains serous fluid from it, then applies a sterile dressing to the wound. The pediatrician tells the patient’s parent how to keep the area clean and also prescribes an antibiotic ointment and shares how and when to apply it. How should I code this encounter? Texas Subscriber Answer: For this encounter, you’ll need to code the procedure performed, an evaluation and management (E/M) service, and diagnoses. To code the incision and drainage (I&D) procedure the pediatrician performed, you’ll use 10060 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single). The pediatrician also provided care that qualifies as an E/M service, including diagnosing the cellulitis, treating it, and prescribing antibiotics to manage the condition. For these efforts, you’ll assign an office/outpatient E/M service code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …), attaching modifier 25 (Significant, separately identifiable evaluation and management service by the same pediatrician or other qualified health care professional on the same day of the procedure or other service) to the E/M for the significant, separately identifiable E/M service that the pediatrician performed in addition to the I&D procedure. To code the condition associated with the bite, the ICD-10-CM Alphabetic index directs you to Cellulitis, upper limb to code the condition when it occurs in the hand. And, as you know the infection is in the right hand, you’ll use L03.113 (Cellulitis of right upper limb). Second, as flea bites led to the cellulitis, you can add a secondary diagnosis. For a nonvenomous insect bite, you’ll use W57.XXX- (Bitten or stung by nonvenomous insect and other nonvenomous arthropods). Don’t forget that you’ll need a 7th character: A (Initial encounter), D (Subsequent encounter), and S (Sequela), based on the episode of care. Assuming this is the first time the patient has been treated for the condition, that would lead you to W57.XXXA. Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
