Wiki right lower quad abdominal wall abscess

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bill2doc

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Op reads:
pt brought to op room placed in supine position. Abdominal wall was then prepped and draped in the standard fashion. Local anesthesia was initiated. An elliptical segment of tissue was incised and passed off the field of the specimen. The abscessed cavity was then entered. Frank pus was evacuated using suction. The abscessed cavity was then copiously irrigated w/ sterial normal saline. The cavity was then packed with 1 inch strips of gauze. Dressings were applied. Patient allowed to awak and brought to recovery in good condition.

First can you help with the CPT code for this procedure.

Second, earlier in the day, doc did a consult for the decision for the surgery. Would I use both 57 and 25 mods on the consult since both consult and procedure were on same day?

Thank you!
 
I&D of abscess, complicated

This is an I&D of an abscess, complicated (because of the use of gauze packing).

I'd have to see all the documentation to tell you whether you could code the E/M service earlier in the day with appropriate modifier.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
I would actually look at 10061 instead, since the packing qualifies as a "complicated" abscess.....as I believe Tessa meant:)
A complicated abscess (or I&D) is when the physician applies any packing, a wick or a drain for further drainage of the abscess.
 
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