I&D infection and Bony Biopy coding question

[VoitChromy]

Can someone help me with this op report. The doctor felt the surgery should be coded as 28002 incision and drainage below fascia, 20245 open bone biopsy and 11730. but a coder in the office said it should be 10180 for I&D complex postoperative wound infection and 20240. thanks for any insight

 

[Orthocoderpgu]

The reason you are having issues with this op note is the documentation. The surgeon did not state how far deep they went as far as tissue is concerned. So your coder, as documented, would be correct wanting to bill 10180. However the surgeon knows that they went deeper than the integumentary system. I think the code 28002 is probably what the physician performed, but then again, there is no indication of specific body tissue. He eventually got down to bone for the biopsy, but how far down was the I&D? What tissue was involved? You don't know because it's not documented. Biopsies taken in the same area of another procedure are generally not reported. As documented 10180 is as close as your going to get since the specific tissue worked on is not documented but there is little doubt that the physician performed 28002, but the documentation needs to support that. 11730 is reportable also. This is where physician education is crucial, they know what they did, the trick is to get their documentation to reflect what they did. Specifics matter.