Wiki Attempted incision and drainage - no drainage

Village of Lakewood, IL
Best answers

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 groin region. A small incision was created in this area and carried down through subcutaneous tissue. The tissue was noted to be quite healthy in this region, both the fascia and the fat. No discolored fluid noted. Since this was thought to be simply a cellulitis, no further incisions were made and no debridement was performed. The area was then packed with quarter inch iodoform gauze and covered with dry dressing. The patient tolerated the procedure well."
I would code it with 11060-52 for reduced services. Be prepared to submit medical records if the insurance requests it.

Hope this helps!

Ardith, CGSC
You do not need to reduce the service just because no fluid was obtained. The procedure itself was completed. There will be no cytology since there was no fluid. However as far as the components of the procedure all were completed.