Wiki Bartholin abscess drainage without incision

[such78]

Dx: Right Bartholin abscess

Hx: Pt states she has been another hospital and had it drained with a wick placed. She came to ER because the wick fell out and she was having increased pain.

Tender, raised, fluctuant mass consistent with abscess. Pus expressed from wound, extensive breaking of loculation was performed with pressure. abscess cavity irrigated with copious amount of NS. Dressing applied.
The abscess is an opening with mild drainage, able to use the opening to express copious amounts of purulent drainage as well as multiple blood clots. Patient felt immediate relief of pain.


There is no documentation indicated when patient had her surgery done.


This service was done in ER, Can i assign 56420 - 52 for this case?



Thank you.

 

[trarut]

That's what I would use since the incision was not needed and not performed. I would also note what wasn't done in the Remarks/Narrative field.

 

[such78]

Thank you

That's what I would use since the incision was not needed and not performed. I would also note what wasn't done in the Remarks/Narrative field.

Thank you.