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I&D of Right Maxillary Abscess w/Intraoral Approach

  1. #1
    Buckeye, Arizona
    Default I&D of Right Maxillary Abscess w/Intraoral Approach
    Medical Coding Books
    I am driving myself crazy trying to find the proper code for this procedure. Any suggestions would be greatly appreciated

    OP Note:
    After the satisfactory induction of general endotracheal anesthesia, a shoulder roll was placed and I examined the right gingivobuccal sulcus. There was prominent fullness, possibly fluctuant, and the gingivobuccal sulcus was infiltrated with 1cc lidocaine 1% with epinephrine 1:100,000. Several minutes allowed for the anesthetic to take effect.

    I made a pass with an 18-guage needle with 10 cc syringe. There was no frank purulence. I then made a sub-centimeter incision with a 15 blade. Murky fluid and gas were expressed and a culture was performed. I then used a very small hemostat to gently break up an abscess pocket, with care not to extend superiorly to the level of the infra-orbital nerve. I then copiously lavaged with bacitracin irrigation solution. Hemostasis was excellent, and this appeared to satisfactorily drain the collection. The child was then lightened from anesthesia, extubated in the operating room, and then brought to the recovery room in good condition.

    Please, please, please, help!
    Thank so much,

  2. Default location?
    the op note states that a particular region was examined.
    It doesn't state the location of the incision. It does mention the gingivobuccal sulcus, and the infiltration with local anesthesia there.
    clearly it's an incision code.
    is the gingivobuccal sulcus where the 18-gauge needle pass occurred?

    Now, in my CPC class we learned that the 18-gauge is considered "core percutaneous needle" so that rules out the fine needle (20-25 gauge from what we learned).
    that eliminates 10021-10022, 10030 is image-guided so that's out too.

    have a look at these two codes as a pick should be one or the other:
    -I&D of abscess (cutaneous or subcutaneous)


    -I&D of abscess cutaneous or subcutaneous)
    -----complicated (we were told foreign body or infection)
    Last edited by ENTcoderConnecticut; 09-18-2014 at 10:02 PM. Reason: picked 2 codes

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