Coder07
Networker
- Messages
- 33
- Location
- Milwaukee, WI
Hello!
I have a note that states the CC as "f/u cyst" ,which the pt was last seen over 4 months ago so to me not a follow up but that not the reason for this post...lol. Now in the HPI it states "A gradual cyst within the left armpit for 2 weeks which is improving seen in ER two days ago for I&D, no antibiotics prescribed, seen at SLER, packing came out yesterday in the shower. Denies swelling, redness, drainage. Less pain, smaller in size."
Then the provider documented...
Administered Lidocaine HCl 2 % SOLN on 04/03/15 02:00pm, and EPINEPHRINE 1:100,000
? Incision and drainage of skin abscess Verbal consent obtained. Verified ID of patient. Skin cleansed with betadine and alcohol. Injected 3cc of 2% lidocaine with epinephrine into lesion. Placed approximately 5cm of iodoform packing into abscess. Procedure well tolerated. Dressed with sterile arm bandage and tape.
Now my issue is obviously this is not an I&D but the provider billed it as an I&D. The provider also has a universal protocol time out sheet that states the procedure as "packing of cyst".
AI was wondering if there is a code that I can use for the packing of the cyst, since the pt did not have the I&D with us there is no global period. My gut tells me just to bill the E/M but I wanted to double check.
I have a note that states the CC as "f/u cyst" ,which the pt was last seen over 4 months ago so to me not a follow up but that not the reason for this post...lol. Now in the HPI it states "A gradual cyst within the left armpit for 2 weeks which is improving seen in ER two days ago for I&D, no antibiotics prescribed, seen at SLER, packing came out yesterday in the shower. Denies swelling, redness, drainage. Less pain, smaller in size."
Then the provider documented...
Administered Lidocaine HCl 2 % SOLN on 04/03/15 02:00pm, and EPINEPHRINE 1:100,000
? Incision and drainage of skin abscess Verbal consent obtained. Verified ID of patient. Skin cleansed with betadine and alcohol. Injected 3cc of 2% lidocaine with epinephrine into lesion. Placed approximately 5cm of iodoform packing into abscess. Procedure well tolerated. Dressed with sterile arm bandage and tape.
Now my issue is obviously this is not an I&D but the provider billed it as an I&D. The provider also has a universal protocol time out sheet that states the procedure as "packing of cyst".
AI was wondering if there is a code that I can use for the packing of the cyst, since the pt did not have the I&D with us there is no global period. My gut tells me just to bill the E/M but I wanted to double check.