Case Study:
Documenting Separate Incisions Can Get Two Procedures Paid
Published on Mon May 01, 2000
Nugget: Coders can find critical information by carefully reading the body of the surgeon's operative report that allows them to get reimbursed for procedures that may not be listed at the beginning.
Although irrigation and drainage (I&D) usually is bundled into the removal of a foreign body, if the two procedures are performed through separate incisions, they may be billed separately as long as both incisions are documented clearly in the operative report.
A coder who only reads the top of the following operative report might assume, on seeing the incision and drainage together with the foreign body removal, that only the removal may be billed.
Operative Report
Preoperative Diagnosis: Abscess, medial aspect right lower leg possibly secondary to foreign body from previous gunshot wound. Retained foreign body from previous gunshot wound, right lateral knee.
Postoperative Diagnosis: Same.
Procedure: Incision and drainage of abscess cavity, medial aspect, right lower leg down through the fascia with debridement of necrotic tissue and packing open of the wound. Removal of retained subcutaneous foreign body, right lateral knee.
History: This 40-year-old man sustained a gunshot wound to the right lower leg about 20 years ago. Approximately two years ago, he began to notice a mass on the medial aspect of the leg, and for about the last three months it has been red, inflamed and draining pus intermittently. It has been drained with recurrence of the abscess. He presents now for incision and drainage with debridement and possible removal of foreign body.
Procedure: Under satisfactory IV sedation and the patient in the supine position, the right leg was prepped and draped. The tourniquet was inflated to 300 mm/mercury on the thigh. The roof of the abscess cavity was very thinned out and was excised after cultures were taken. The inflammation appeared to go through the fascia, so the fascia was opened. There was a mass of inflammatory tissue on the fascia and this was sharply debrided. The abscess cavity was totally explored and all necrotic tissue removed. Using fluoroscopy, I located the retained foreign body that was on the medial aspect of the left, and it was far posterior and well away from this wound so it was left in place. It was deep within the muscle belly. Using fluoroscopy, we identified the mass laterally as a small transverse incision made overlying it. A lead B-B was removed. The tourniquet was deflated and good hemostasis noted. A couple of bleeding points were controlled with electrocautery. The lateral incision was closed with two interrupted nylon simple sutures. The medial wound was packed open with Iodoform gauze and a gauze dressing applied. An Ace wrap was applied to hold it in place. The patient was then removed from the operating table [...]
