For 20525 I will be looking for certain key phrases to tell me this is warranted ... "deep" or "complicated" or evidence that the wound was "dirty" or required "packing."
I ask my surgeons to "title" their op notes for FB removal so that I specifically know what it is THEY are thinking ... is is "deep" ... is it "complicated" ... do you have a "contaminated wound" or did they need "gauze packing"
It seems this was pretty straightforward, but I can't tell if your statement that it was 6-7 cm from entry and imbedded in tissue is actually part of the surgeon's dictation or just what you learned after you queried the physician.
Not seeing any of the key phrases/words in the dictation, I would have coded it as 20520.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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