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?
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?