1. A

    Wiki Need Help with parapharyngeal abscess!

    Doctor said he did a procedure for incision and drainage of parapharyngeal abscess. But in the procedure details it says there was no drainage and no abscess found. Below is the op report: Procedure: Incision and drainage of parapharyngeal abscess Procedure details: Patient was taken to...
  2. N

    Wiki 2wk c/s incision check

    Not sure what the best code would be for the incision check. Thanks for the suggestions.
  3. M

    Wiki help with surgery please

    PREOPERATIVE DIAGNOSES: 1. Right severe flatfoot deformity 2. Right PTTD 3. Right Hallux valgus 4. Hallux elevatus POSTOPERATIVE DIAGNOSES: Same PROCEDURE: 1. Right triple arthrodesis 28715 2. Right 1st Tarsal-metatarsal joint arthrodesis 28740 3. Right medial calcaneal...
  4. P

    Wiki Attempted incision and drainage - no drainage

    Hi, How would you code an attempted incision and drainage, but nothing drained when the incision was made? Preop dx: cellulitis of groin concerning for necrotizing fasciitis Post op dx: cellulitis of left groin region. Here is the op note: "Area of induration was identified in the left...
  5. A

    Wiki Encounter After Surgery

    Neurosurgeon did laminectomy on patient about a year ago. Patient presents for post operative examination. No complications and incision has healed. I cant seem to find anything for encounter of musculoskeletal. Any thoughts?
  6. J

    Wiki I&D Scrotal Abscess

    PROCEDURES IN-OFFICE: SURGEON: Emily White FNP FINDINGS AND PROCEDURE: Patient was placed in a supine position. Patient has a scrotal abscess. The area was prepped and draped. The abscess was incised, purulent material drained, and the cavity was irrigated with sterile water. Incision was...
  7. T

    Wiki C-section with bladder injury, pt returns for follow-up

    I'm just not sure how to code this postpartum office visit: Subjective: Patient here for incision check Had repeat C-section (date) with incidental cystotomy Bladder injury was repaired in 2 layers with intraoperative retrograde bladder fill with no leak Patient has leg bag and will use for...
  8. S

    Wiki Burr Hole PCS

    Patient was taken to the OR for burr hole drainage of subdural hematoma. Small incision made in the right temporal area and then burr hole with drain placement. We didn't code this to an open procedure because the skull didn't have to be opened prior to the drill. Are we correct? Or would...
  9. K

    Wiki Open evaluation under anesthesia

    I am searching for a code for an open evaluation under anesthesia. The Dr. initially intended to remove a soft tissue mass but after incision was made he diagnosed the patient with a dilated venous plexus, closed the incision and refferred the patient onto a vascular surgeon. Does anyone know if...
  10. R

    Wiki Pip synovectomy

    I need help with the above CPT. Op note reads: Incision was made overlying the dorsal aspect of the middle finger. Subcutaneous tissues were divided. Synovitis was noted to protrude the interstices of the extensor mechanishm. The synovium was removed in its entirety and sent to pathology...
  11. M

    Wiki I&D or E/M?

    New patient presents in office to have wound repacked after I&D of the gluteal crease from another physician. Encounter form indicated packing. I informed the physician that I was not aware of a packing code and that an E/M can only be charged since there was no incision. After speaking to the...