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Wiki I&D help, please

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coder25

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Hello,

Not sure how to code this and need some help.

Pt had an ID on left side of groin and then 18 days later developed right groin pain and a lump. Given the likelihood of an underlying abscess and his history of left groin abscess, decision was made to perform an I & D, however, following the incision there was no pus noted. Three days later, there was pus noted. How would I bill this out?? Would it be an I & D on the right?

Thanks for the help
 
Need to see the documentation

In general the rule is that doctors document what they do and coders code what is documented. I know that doesn't help much ... Can you post the note(s)?

F Tessa Bartels, CPC, CEMC
 
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