solocoder
Expert
My doctor did a sx to remove a "painful lesion with possible foreign body". There turned out to be no foreign body. Just an excision of scar tissue. He wants to use the codes for "foreign body" 729.6 and "removal of foreign body" 28192 anyway. Doesn't seem appropriate to me. Here is the note:
An approximately 2-cm semi-elliptical incision was carried out, excising the painful lesion. The lesion was examined on the back table. No evidence of foreign body was seen. Deep examination on the wound did not demonstrate evidence of foreign body. The lesion was sent for pathological analysis. Following copious amounts of irrigation, deep closure was obtained using 3-0 Vicryl in a simple interrupted fashion. Skin closure was obtained using 3-0 nylon with a combination of horizontal mattress in a simple interrupted fashion.
If I can get him to document a depth, would an excision code, and a repair be more appropriate?
An approximately 2-cm semi-elliptical incision was carried out, excising the painful lesion. The lesion was examined on the back table. No evidence of foreign body was seen. Deep examination on the wound did not demonstrate evidence of foreign body. The lesion was sent for pathological analysis. Following copious amounts of irrigation, deep closure was obtained using 3-0 Vicryl in a simple interrupted fashion. Skin closure was obtained using 3-0 nylon with a combination of horizontal mattress in a simple interrupted fashion.
If I can get him to document a depth, would an excision code, and a repair be more appropriate?