Wiki splinter not found, carbuncle DX?

[tag60]

Pt comes in with possible splinter. Can we still code removal of FB (10120) if none is found? (Actually provider chose I&D as procedure code, but I think not...) Also, what DX code to use? Provider says "carbuncle," though I'm not sure I see it in description below. Here's the note:

Pt comes in with hand pain, swelling, possible splinter. A week prior, she had opened a wooden umbrella, got a splinter, husband removed. But she has continued to have pain and a small area of swelling.

Procedure: Pt signed informed consent. Area was prepped with alcohol. Sterile needle was used to inject 1 ml lidocaine into dermis. An 11 blade was used to superficially open center of lesion. No purulent drainage obtained. No foreign body obtained. No packing placed. Wound was cleaned and dressed.

Exam of hand: 1 cm area of thenar eminence with necrotic center. No active drainage. Positive tenderness. Mild surrounding induration. No obvious foreign body. No erythema. Digits with FROM and sensation after procedure completed.

Assessment/Plan: Carbuncle, 680.9. X-ray of left hand ordered to rule out foreign body. Warm soaks 3x/day. Antibiotic (Keflex) given. Recheck in 2-3 days.

I would code as superficial injury, hand (914.8), and incision and removal of foreign body (10120) though none was found. Agree?

 

[jorzano55@gmail.com]

Curious as to why you want to use these codes, what is your justification?

A carbuncle is a infection/inflammation which is what the doctor described under his exam note. He mentioned twice in his note no foreign body found.

His note states he performed an incision and there was no drainage but the procedure remains a I&D. You can't claim you removed something when you didn't and your states you didn't.

Your diagnosis is Carbuncle. In this case I would agree with the doctor's coding.

 

[mitchellde]

Curious as to why you want to use these codes, what is your justification?

A carbuncle is a infection/inflammation which is what the doctor described under his exam note. He mentioned twice in his note no foreign body found.

His note states he performed an incision and there was no drainage but the procedure remains a I&D. You can't claim you removed something when you didn't and your states you didn't.

Your diagnosis is Carbuncle. In this case I would agree with the doctor's coding.

I agree with this response. You indicate the notes states possible splinter and we cannot code a diagnosis documented as possible or suspected. I too agree with the provider.

 

[tag60]

Thank you both for your help with this! I'm still learning so much. I just felt there was intent to excise a splinter, but I obviously need to be very careful in reading the documentation. I appreciate the help.