99212 and toenail removal 11730

[oskolkoff]

Does this documentation support 99212 along with 11730?

A pt came into the clinic CC: ingrown toenail.

HPI:
Location Lt Hallux. Toe pain moderate. Redness, swelling, warmth at toenail and discharge. 3-4 weeks with nail pain.

ROS:
Nail was torn 1 month ago. Now swollen and painful. Has tried soaks and topical antibiodic ointment. Had ingrown nail a few years ago. Nail was removed but grew back. Interested in getting nail removed if needed.

Exam:
Constitutional: Pt awake, alert, well groomed, cooperative, and appropriate

Respiratory: Pt relaxed, breathes without effort.

Extremities: Inspection and palpation of digit reveals no clubbing, cyanosis, petechiae, or Osler's nodes. L great toe with ingrown toenail, medial>lateral, medially showing granuloma overlying, redness, tenderness and warmth of tissue with scan purelent drainage from under nail.

Psychiatric: Pt is oriented to person, place and time. Speech is fluent and words are clear. Pt"s mood is neutral and the affect appropriate.

Procedure Note:
informed verbal consent obtained (risks include infection, pain, bleeding, nail regrowing with deformity)
Toe nail avulsion and ablation
1st L great toe local anesthesia with digital block 2% lidocaine/marcaine mix with good effect
nail elevated without difficulty and removed
silver nitrate used to cauterize medial granuloma and medial and lateral corners of nail matrix bed.
cleaned with saline, ointment and sterile dressing applied,

DX: Ingrowing Nail 703.0, Onychia And Paronychia Toe 681.11

Care Plan:
Note:
paronychia: keflex rx sent

ingrown nail: removed with partial ablation.


Thanks for the help,
Jennifer

 

[bethdreaux]

99212 & 11730

Your coding looks good assuming the patient is an established patient.
99212 -25
11730 -TA
I would also add 729.5 in the Dx for the pain.

 

[OCD_coder]

Pain diagnosis is not necessary as that is considered part of the Paronychia Dx, this is a stated in the ICD-9 Guidelines. I would however, link the dx specific to the E&M with the 681.1 as that is the medical necessity to support the E&M/Keflex documented separate from the procedure note for the ingrown toenail 703.0.