Patient had an I&D done on 10/01/12. Physician billed 21501. I can't find his OP note and I'm pretty sure that's not what should have been billed. Anyhow, patient comes back two days later- and again, 21501 was billed. I have the OP note for the second surgery and I really feel it should be a post-op visit and no charge. Here's the OP note:
...has a history of a severe MRSA infection of the neck. He has undergone two previous procedures to drain this wound. He presents today for elimination of any residual abscess material and a dressing change.
Patient was transferred to operating room. Neck was prepped and draped. At this point, the NU Gauze packing material was carefully removed. The wound was probed and a small area of retained abscess material was opened in the superior aspect of the wound. The remaining wound was granulating. A 1/2 inch idoform dressing was then placed after first debriding a small amount of necrotic tissue. I don't feel this is enough for a debridement code either. Procedure was termed and patient was transferred.
Thoughts?
...has a history of a severe MRSA infection of the neck. He has undergone two previous procedures to drain this wound. He presents today for elimination of any residual abscess material and a dressing change.
Patient was transferred to operating room. Neck was prepped and draped. At this point, the NU Gauze packing material was carefully removed. The wound was probed and a small area of retained abscess material was opened in the superior aspect of the wound. The remaining wound was granulating. A 1/2 inch idoform dressing was then placed after first debriding a small amount of necrotic tissue. I don't feel this is enough for a debridement code either. Procedure was termed and patient was transferred.
Thoughts?