I will preface that I am working through Practicode, and I have emailed the coach regarding this case, but they stand firm with the code selection 27301-LT.
The only issue that I have is that the explanation that was provided is still not helping me understand. I had chosen CPT code 10061, but the coach responded thus:
In this scenario, anatomical code is available to use…best to use versus 10060 which does not specify site:
Since they had only said the anatomical code is available to use, I am actually just more confused since I believe the real reason is more likely due to depth. I am not sure according to the following documentation including, "Incision was carried down to the skin and subcutaneous tissue." The depth of the incision is to subcutaneous tissue, but the CPT code 10061 states: "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple" If anyone can help me understand, I would appreciate it!
PREOPERATIVE DIAGNOSIS: Left thigh gluteal (posterior) abscess.
POSTOPERATIVE DIAGNOSIS: Left thigh gluteal (posterior) abscess.
PROCEDURE PERFORMED: Incision and drainage of left thigh gluteal (posterior) abscess.
ANESTHESIA: Spinal.
INDICATIONS: A male with a 2-day history of swelling and erythema along the posterior left gluteal thigh, findings consistent with abscess and cellulites.
FINDINGS: Multiloculated abscess, no evidence of fascitis.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in the supine position, given a spinal IV sedation anesthetic due to a family history of malignant hyperthermia. After proper anesthesia, he was prepped and draped in the usual sterile fashion. A transverse hockey stick incision was made over the palpable pocket of induration and fluctuance. Incision was carried down to the skin and subcutaneous tissue. A large abscess cavity was encountered. Cultures were taken. Pockets were all broken up for digital manipulation and dissection. Once proper dissection had been carried that all pockets were uncovered. The wound was irrigated with saline and then packed with Kerlix. The patient tolerated the procedure well. There were no apparent complications. Lap, sponge and instrument counts were correct.
The only issue that I have is that the explanation that was provided is still not helping me understand. I had chosen CPT code 10061, but the coach responded thus:
In this scenario, anatomical code is available to use…best to use versus 10060 which does not specify site:
| 27301 |
| Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region |
Since they had only said the anatomical code is available to use, I am actually just more confused since I believe the real reason is more likely due to depth. I am not sure according to the following documentation including, "Incision was carried down to the skin and subcutaneous tissue." The depth of the incision is to subcutaneous tissue, but the CPT code 10061 states: "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple" If anyone can help me understand, I would appreciate it!
PREOPERATIVE DIAGNOSIS: Left thigh gluteal (posterior) abscess.
POSTOPERATIVE DIAGNOSIS: Left thigh gluteal (posterior) abscess.
PROCEDURE PERFORMED: Incision and drainage of left thigh gluteal (posterior) abscess.
ANESTHESIA: Spinal.
INDICATIONS: A male with a 2-day history of swelling and erythema along the posterior left gluteal thigh, findings consistent with abscess and cellulites.
FINDINGS: Multiloculated abscess, no evidence of fascitis.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in the supine position, given a spinal IV sedation anesthetic due to a family history of malignant hyperthermia. After proper anesthesia, he was prepped and draped in the usual sterile fashion. A transverse hockey stick incision was made over the palpable pocket of induration and fluctuance. Incision was carried down to the skin and subcutaneous tissue. A large abscess cavity was encountered. Cultures were taken. Pockets were all broken up for digital manipulation and dissection. Once proper dissection had been carried that all pockets were uncovered. The wound was irrigated with saline and then packed with Kerlix. The patient tolerated the procedure well. There were no apparent complications. Lap, sponge and instrument counts were correct.