Wiki I&D or EM

[kelhop1@msn.com]

Looking for opinion on how to bill this. Patient comes in for possible yeast infection and bump on left vulvar area. Provider injected boil with lidocaine and it started to drain. Provider did not do another incision just milked. Provider put 56405. I'm not sure if I want to use modifier 52 as the provider did drain the boil, but not sure. Thanks

 

[csperoni]

Per this article on AAPC (https://www.aapc.com/blog/34676-superficial-incision-drainage-abscess/), puncture with a needle is not considered I&D at all and is included in the E/M service.
If you feel the documentation does support something more than E/M, then definitely add -52.