Incision & Drainage post infection

stacyk1969

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Patient comes in 2 days after I & D performed, has infection at the site. Dr. does more drainage, wound packing. I don't think the initial procedure of 10060 has a global period so I want to code this visit with E/M (??)also not sure what Dx codes to use. here is the dictation. Any Ideas? Thanks!! Wound is on the chest :confused:

Procedures

Wound Check / Suture / Staple Removal
Wound Examination
The wound has edema, exudates, purulent drainage. The wound appears infected.

Wound Care
Wound Care performed: wound packed with iodoform gauze. Local anesthesia was used.

Patient was provided with wound care instructions. Call for chills, fever, pain Patient was advised to return for a follow up wound check visit in 2 days.

Comments: The cellulitis has localized more around the indurated area. There is no extension of the cellulitis. I opened the area up a little more and got another 5-6cc of purulent drainage. No material could be expressed from the lateral area of induration. Culture results not available at this time.
 
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