# BEDSIDE I&D - Not sure if this is billable



## coder25 (Dec 15, 2010)

Good morning!

My doc performed a bedside I&D on a patient with a right thigh abscess.  He wrote a short procedure note (see below)

PROCEDURE NOTE:
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.

Opinions, please!

Thanks!


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## surgonc87 (Dec 15, 2010)

put in consideration of global days, or postop infection/abscess on a prior incision for the correct Dx and or a more extensive I&D.....

But as is, it is reportable with 10060 in my opinion, although I would ask for an addendum for him/or to elaborate more on documentation for compliance reasons and to protect yourself as well.

MS


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## FTessaBartels (Dec 15, 2010)

*Can be billed bedside*

You certainly can perform and code an I&D performed at bedside.  HOWEVER ... I think your documentation is lacking description of the procedure in this case. 

Ask your doc to dictate a note that expounds on what s/he actually did. Most often when a wound requires gauze packing following I&D we code with 10061.  I see mention of "wound packed" -- but again, need more detail to accurately code. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## coder25 (Dec 15, 2010)

Thanks for your responses.  That is what I thought, but I wanted to be sure.


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