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BEDSIDE I&D - Not sure if this is billable

  1. #1
    Default BEDSIDE I&D - Not sure if this is billable
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    Good morning!

    My doc performed a bedside I&D on a patient with a right thigh abscess. He wrote a short procedure note (see below)

    DX: Right thigh abscess
    PROCEDURE: Bedside I&D
    SURGEON: Dr. C
    ASSIST: Dr. L
    SPECIMEN: Culture x1
    DISP: Stable, wound packed, pus drained.

    I think I know the answer to my question, but I wanted to be sure before speaking with the doctor. Is this an acceptable note to bill out for an I&D, or should he dictate a proper OP note. I feel a more formal OP note should be done, but wasn't sure for this bedside I&D.

    Opinions, please!


  2. #2
    put in consideration of global days, or postop infection/abscess on a prior incision for the correct Dx and or a more extensive I&D.....

    But as is, it is reportable with 10060 in my opinion, although I would ask for an addendum for him/or to elaborate more on documentation for compliance reasons and to protect yourself as well.


  3. #3
    Milwaukee WI
    Default Can be billed bedside
    You certainly can perform and code an I&D performed at bedside. HOWEVER ... I think your documentation is lacking description of the procedure in this case.

    Ask your doc to dictate a note that expounds on what s/he actually did. Most often when a wound requires gauze packing following I&D we code with 10061. I see mention of "wound packed" -- but again, need more detail to accurately code.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Thanks for your responses. That is what I thought, but I wanted to be sure.

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