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Posted By jan on 04-10-2002, 14:44:00 in Emergency Department

The MD states HPI elements qualifying for L4 and para phrasing says pt
has hx of mastectomy sent to ED for possible cellulitis and abscess at
suture site. ROS and PFSH OK for L4
Exam OK L4 also and talks about staples in place, erythema extending
the length of wound, particularly in anterior axillary region with warmth,
induration and purulent drainage from that site.
ED MD states discussed with surgeon, at his instructions, sutures were
removed. The wound was probed and drained as well as irrigated. Large amt
purulent material drained. Packed wiht iodoform gauze.
Final diag: Wound infection status post I&D.
I am not sure there's a procedure here at all. I&D .10060,10061 had
no real incision done, as pt already had one and it opened up with suture
removal(he states but pt did only have staples)Sounds like he probed with
probably forceps and it just drained out.
Not sounding at all to me like puncture aspiration either.10160

What do you all think?? I vote for E&M only.I"m ready for your votes.
Thanks, It's so interesting to hear other's interpretation on what I think
is so clear.
Comments (5)
Posted By jan on 04-11-2002, 10:20:00
Once again you have clarified the situation from a clinical standpoint. I
talked to the MD and this is exactly what he did. I am re-calling my E&M
vote for a recount, I'm going for the 10180.
Posted By Stacie on 04-10-2002, 22:51:00
According to the Coders Desk Reference the definition for 10180 states
that the physician either removes the surgical sutures or staples or makes
additional incisions into the skin and then the wound is drained of fluid.
This makes it sound like they can do one or the other. I would use the
10180 code.
Posted By jan on 04-10-2002, 16:01:00
My thought was he might have had to actually use a scapel to extend incision
but maybe not. Reading the Medicode book ( which is good but I try not to
use it as the absolute resourse,) really does not say incision extended or
even made. This is what is fun, now I have another aspect to look at. I
think I got stuck looking at the I&D part needing an incision with scapel.
Posted By Vicki on 04-10-2002, 15:23:00

Why not a 10180? The doctor did remove the staples and irrigated and
packed it. Would he HAVE to extend the incision to use this code?

Posted By sheri on 04-10-2002, 15:04:00
Agree. Would code E/M only.

Sheri Modell

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