Margaret Posted Wed 15th of December, 2010 12:48:33 PM
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.
Thanks in advance for your help!
SuperCoder Answered Wed 15th of December, 2010 22:24:42 PM
I agree with you that we need additional documentation for coding I & D. But, in case like this, we need to request the doctor to document some specific additional lines (details of dissection of layers and closing or repairing the site) to make the documentation to justify the medical necessity so as to code for the procedure.
As a Coder we should take the responsibility to educate the physician regarding documentation details if there is lacking in documentation of the report for coding the particular procedure.
Margaret Posted Thu 16th of December, 2010 00:15:43 AM
Thanks Sanjit for responding! This is what I thought that more info was definitely needed before billing the I&D out!