Wiki Possible I&D coding

[tlwhlw]

Not quite sure how to code this; was first thinking I&D, 10060, but not certain. Any thoughts??

Lump at side of umbilicus on L. Erythema, fluctuation noted, and purulent discharge.

Assessment & Plan:
# ABDOMINAL OR PELVIC SWELLING MASS OR LUMP PERIUMBILIC (789.35): On L. ?foreign body vs lipoma. Close to previous abdominal surgery surgical line, ? suture.
# CELLULITIS AND ABSCESS OF TRUNK (682.2): Draining of the abscess done on the lesion, abx. Iodoform packing strip applied as well. After verbal consent obtained, area is cleansed. The patient tolerated the procedure well. No immediate complications noted.

 

[missy874]

Did the provider document how the drainage was performed? From what's posted, I don't see any indication of incision. There have been times where providers have only provided pressure to a lesion and drainage resulted--for those, I only allow the e/m. I would want more documentation before I gave a procedure code for this encounter.

 

[tlwhlw]

After speaking with the physician, he did not do an incision. He basically examined, cleansed and covered the affected area. There was a little further drainage, but nothing cut. So this should just be and E/M code only...