Abscess-This patient

cnramsey

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This patient had and I&D for this abscess by our provider. At time of this visit below the patient was still under their 10 global care period. I'm confused on how to bill this due to the patient seeing the provider and than the provider having our surgeon come over and do a procedure on them. Would I only charge for the sugeon opening the abscess and not charge for the office visit for my provider? The surgeon is part of or facility..we are all under the same tax ID number.

CC: abscess check .

History of Present Illness:
pt here for abscess recheck. he/she has been on abx and had had his/her first abscess drained. he/she now has packing removed. he/she has a continued baseball sized mass in the left buttocks. this area is very tender. he/she denies any fevers or chills.

Review of Systems
See HPI

Vital Signs:

Patient Profile: 62 Years Old
Height: 67 inches
Weight: 224 pounds
BMI: 35.21
Temp: 97 degrees F tympanic
Pulse rate: 76 / minute
Pulse rhythm: regular
Resp: 20 per minute
BP sitting: 122 / 70 (left arm)
Cuff size: regular

Vitals Entered By:

Physical Exam

General:
well developed, well nourished, in no acute distress.
Skin:
resolving still draining abscess left buttocks. larger abscess was opened through first abscess.
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.


Impression & Recommendations:

Problem # 1: ABSCESS, SKIN (ICD-682.9)
i called the Surgeon over. he/she was able to use a bent forcepts to puncture open the baseball sized abscess deep to skin. this was done allowing an orange material to evacuate. pt did feel better. after reviewing the culture and sensitivity i decided to have pt remain on flagyl for an additional ten days. he/she will soak in hot water 1-2 x per day. he/she will continue to massage abscess. he/she will call if any further issues arrise.

His/Her updated medication list for this problem includes:
Cipro 500 Mg Tabs (Ciprofloxacin hcl) ..... One tab po bid
Flagyl 500 Mg Tabs (Metronidazole) ..... One tab po tid
 
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Milwaukee WI
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Global period

Based on the info you provided in your post ...
The surgeon who was called over may bill for his/her services - if - Big, Red, IF .. s/he is of a different specialty that your provider.
Your provider's service is covered under the global period for the original I&D (10 days) - you would code 99024.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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