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Wiki Lesion Removal?

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Nancy R Parent

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Barrington, NH
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One of our ER physicians charted the following entry; I'm not sure of the CPT code as he clearly states lesion in all areas, yet it is not excised, shaved or removed. I'd appreciate any help.

"is a very small 0.5 cm diameter slightly erythematous raised lesion just lateral to midline and the left antecubital area. There is a linear abrasion overlying this area which he says he has been scratching and it opened up. Had been bleeding before no purulent discharge. He has had a history of infections and abscesses in the past. He denies drug use. It does look like he has some track marks however.

the area was locally anesthetized and opened without any purulent discharge. it was just some bleeding."
 
I agree, except how did the provider "open" it? Did he incise the lesion or just puncture it? I would query him, since if he only punctured it, you can't bill for I&D, and then you probably just have an E/M.
 
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