# I & D procedure note requirements



## jaciwismar (Jul 17, 2013)

What are the procedure note requirements for an I & D?   Does the doctor have to specify the blade that was used? 
Thank you
Jaci


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## a.montaruli@gmail.com (Jul 17, 2013)

The provider must document the location and simply describe the procedure performed so that the coder may identify the difference between a simple or complicated I&D. Yes this should include the #blade used as well as properly documenting that the area was prepped before the incision. The complex I&D's would usually include probing, loculations and placement of packing or drains. 

Hope this helps!

Andrew Montaruli


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## jaciwismar (Jul 18, 2013)

Thank you for your response, Andrew.  If the provider failed to document the #blade, would you not give him credit for the I & D?  Where do i find the documentation requirements for the procedure?   Thanks!


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## a.montaruli@gmail.com (Jul 22, 2013)

I would send it back, yes. It is the doctor's responsibility to document every portion or of the procedure just as he/she would do in the OR. This absolutely includes the instruments used. Even a cerumen removal procedure requires documentation of what tool was used past the initial flush. I found this information in the CEDC Study Guide. I will try to do a little research for you to see if I can get it from a higher source. Hope this helps!

Andrew


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## jaciwismar (Jul 30, 2013)

Thanks Andrew!  I'm just having a hard time providing a good source for things that I 'know to be true".


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