Primary Care Coding Alert

Question: I am not sure which codes to assign for the following procedure. Is there enough physician work documented to report an E/M code along with the procedure code? Also, which diagnosis code would be best?

Patient here for follow-up of an emergency department visit. Had evacuation of a hematoma last week. She subsequently noted some purulent drainage and was seen in the ED two days ago. Culture was taken at that time and she was started on Dicloxacillin. She has continued to note some purulent drainage, but seems improved. There is some mild erythema and firmness around the incision site, but no fluctuance and just some fibrinous covering of the incision. Local anesthesia with 1% lidocaine with epinephrine was injected. The wound was opened with a scalpel and a small amount of serosanguinous drainage was noted, but no frank pus. The wound was explored well, and irrigated with normal saline and hydrogen peroxide. It was packed with plain new gauze and patient will be seen tomorrow to recheck the wound.

Hawaii Subscriber

Answer: In this instance it is appropriate to assign 10180 (incision and drainage, complex, postoperative wound infection) to describe the procedure. In addition, the family practice can report an office visit code (e.g., 99212) modified with -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

The best diagnosis code is 682.x (other cellulitis and abscess), with the additional digit indicating the site of the infection. Because the patient returned after a week on antibiotics with continuing signs of infection (e.g., redness, swelling, pain, drainage, heat), most FPs consider the cellulitis incompletely treated and as standard procedure prescribe the second course of antibiotics.