ED Coding and Reimbursement Alert

Question: A patient reports to the ED with a swollen bump on her left arm. Notes indicate that the physician performed an incision and drainage (I&D) on the wound, sent the patient home, and instructed her to follow up with her primary care physician in five to seven days. Can I report a separate E/M in this scenario?

Minnesota Subscriber

Answer: If the chart contains only the information in your question, then you should not code a separate E/M.

On the claim, report 10060 (Incision and drainage of abscess [e.g. carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) with 682.3 (Other cellulitis and abscess; upper arm and forearm) appended to represent the patients wound.

Your physician likely provided a separate E/M for this patient prior to the I&D; given the nature of EDs, an E/M service is almost a given before a patient receives an I&D.

Without proof of that service in the notes, however, you cannot report a separate E/M.

Do this: Encourage physicians to show the separate nature of any pre-procedure services in the notes -- meaning the provider should clearly show that he performed a separate history, examination, and medical decision making before deciding on treatment (I&D).

Consider your scenario: Lets say the encounter notes stated: Patient has painful, swollen lump on left forearm. This is third day of injury; pain 4 on a scale of 10 but worsening daily. No constitutional symptoms, or forearm injury other than lump. Using scalpel, cut x over wound and drained pus, prescribed antibiotics, and instructed px to follow up with PCP 5-7 days.

If you had this much information in the notes, you might be able to report 10060 and a low-level separate