Wiki Office Procedure by Surgeon

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MidwestCoder

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Wadena, MN
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This is the procedure note..

The area was prepped and draped in a sterile fashion and anesthetized and the abscess was drained but he seems to have multiple areas of tracts that will require further d?bridement in the operating room. His INR is 2.1 and we will have him hold his Coumadin also.



Visit Diagnoses and Associated Orders
Abscess - Primary ICD-9-CM:
682.9
ICD-10-CM:
L02.91
INCISION AND DRAINAGE OF ABSCESS; SIMPLE OR SINGLE [10060 CPT(R)]


Can someone please help?
 
I am not sure what the question is. It looks right but it is a half you know what'd note. It should specifiy where on the body, what anesthesia was used, what instrument was used to incise and what and how much was expressed. If it was me I would ask the provider to redo and add the elements but I know some would just accept it as it is.
 
This is all of the information that is given? I am wondering if this would be the correct procedure code for what he is doing? He is not real specific with what he is doing for the procedure?
 
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