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Posted By DICK BURNAL on 09-27-2019, 08:09:27 in Podiatry

In our Podiatry documentation we are getting most of the cases with Hematoma removal procedure description as below,

From the documentation the below procedure description was given,

I was able to debride the injured portion of nail plate to better evaluate the nail bed for deep tissue involvement and assess for laceration or ulcer formation. X-rays are not medically warranted at this time as there are no other overt signs of trauma. I was able to remove most of the hematoma today. I applied triple antibiotic ointment and a dry dressing. Please cleanse with normal saline, pat dry, apply triple antibiotic ointment and a dry dressing daily until resolved. Please call if the area becomes red, hot or swollen or if any other pedal concerns arise.

And while evaluating the Hematoma from Examination it was given as below,

There is a subungual hematoma under the nail plate of the right 5th toe involving the entirety of the plate. However, there are no gross signs of infection or other complications identified.

As subungual is under the nail, from the Physical examination it states Hematoma is under the nail plate, and Physician removes the Hematoma we are giving 11740 Evacuation of subungual Hematoma.

Does this documentation was enough to code 11740 or else E/M was supportive from above criteria.

Please do the needful.

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