BEDSIDE I&D - Not sure if this is billable

coder25

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Lehigh Valley
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Good morning!

My doc performed a bedside I&D on a patient with a right thigh abscess. He wrote a short procedure note (see below)

PROCEDURE NOTE:
DX: Right thigh abscess
PROCEDURE: Bedside I&D
SURGEON: Dr. C
ASSIST: Dr. L
SPECIMEN: Culture x1
DISP: Stable, wound packed, pus drained.

I think I know the answer to my question, but I wanted to be sure before speaking with the doctor. Is this an acceptable note to bill out for an I&D, or should he dictate a proper OP note. I feel a more formal OP note should be done, but wasn't sure for this bedside I&D.

Opinions, please!

Thanks!
 

surgonc87

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Atlanta
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put in consideration of global days, or postop infection/abscess on a prior incision for the correct Dx and or a more extensive I&D.....

But as is, it is reportable with 10060 in my opinion, although I would ask for an addendum for him/or to elaborate more on documentation for compliance reasons and to protect yourself as well.

MS
 
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Milwaukee WI
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Can be billed bedside

You certainly can perform and code an I&D performed at bedside. HOWEVER ... I think your documentation is lacking description of the procedure in this case.

Ask your doc to dictate a note that expounds on what s/he actually did. Most often when a wound requires gauze packing following I&D we code with 10061. I see mention of "wound packed" -- but again, need more detail to accurately code.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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