Wiki I&D or E/M?


Chesterfield, VA
Best answers
New patient presents in office to have wound repacked after I&D of the gluteal crease from another physician. Encounter form indicated packing. I informed the physician that I was not aware of a packing code and that an E/M can only be charged since there was no incision. After speaking to the physician, he did indicate that he deride into sub-q tissue before packing.

The code that I chose was 11042 Debridement; skin, and subcutaneous tissue.
Does this code selection seem correct or am I over looking something?
You need to go by what is in the documentation, not by what the dr tells you they did when you asked them about it.

As to if that it is the correct code, it is impossible to decide that, since we don't know what is in the note from the procedure / encounter.
Does documentation support 12021?

There has been a breakdown of the healing skin either before or after suture removal. The skin margins have opened (<--This may be the deciding factor). The physician cleanses the wound with irrigation and antimicrobial solutions. The skin margins may be trimmed to initiate bleeding surfaces. Report 12021 if the wound is left open and packed with gauze strips due to the presence of infection. This allows infection to drain from the wound and the skin closure will be delayed until the infection is resolved.