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Wiki I & D procedure note requirements

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jaciwismar

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What are the procedure note requirements for an I & D? Does the doctor have to specify the blade that was used?
Thank you
Jaci
 
The provider must document the location and simply describe the procedure performed so that the coder may identify the difference between a simple or complicated I&D. Yes this should include the #blade used as well as properly documenting that the area was prepped before the incision. The complex I&D's would usually include probing, loculations and placement of packing or drains.

Hope this helps!

Andrew Montaruli
 
Thank you for your response, Andrew. If the provider failed to document the #blade, would you not give him credit for the I & D? Where do i find the documentation requirements for the procedure? Thanks!
 
I would send it back, yes. It is the doctor's responsibility to document every portion or of the procedure just as he/she would do in the OR. This absolutely includes the instruments used. Even a cerumen removal procedure requires documentation of what tool was used past the initial flush. I found this information in the CEDC Study Guide. I will try to do a little research for you to see if I can get it from a higher source. Hope this helps!

Andrew
 
Thanks Andrew! I'm just having a hard time providing a good source for things that I 'know to be true".
 
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