Question: Our physician documented treating an abscess on a patient’s knee due to a fall, but when I looked at his notes, I saw that he did not perform incision and drainage, and did not prescribe an antibiotic. I went to him and double-checked, and he told me that he accidentally wrote down “abscess” when he actually meant to say “hematoma.” What is the difference between these conditions, and how can I correct the chart?
South Carolina Subscriber
Answer: An abscess is defined as a localized collection of pus in any part of the body, whereas a hematoma is a swelling or mass of blood, confined to an organ, tissue or space, caused by a break in a blood vessel.
To code for this patient, use 924.11 (Contusion of lower limb and of other and unspecified sites; knee). Try to find out what kind of fall the patient had and select an E code to specify the circumstances.
As for correcting the chart, the physician can make a notation in the documentation that corrects the error. He should sign and date the corrected notation.