Wiki Help! In office procedure

[Jenannurb]

My surgeon performed here in our exam room (according to our office notes) and incision and drainage for a perirectal abscess.
"cleansed the perirectal area with Betadine/sterile soap. Area antesthetized with lidocaine local infiltration. Incision and drainage performed. Expressed purulent contents. Sterile gauze dressing applied. Hemostasis achieved. No complications, patient tolerated the procedure well"

He wants to code it with CPT 46040... I'm not quite convinced that it was more than an incision and drainage 10060... Any thoughts?

 

[ahonkomp]

In my opinion, your provider is correct in his code assignment: 46040 so long as the diagnosis of perirectal abscess is accurate.

 

[Jenannurb]

thank you for your input