nc_coder
Expert
Our physician saw a pt with a perianal abscess
Opnote states:
The area was aspirated percutaneously. An incision was made and the abscess cavity was entered. Pus was evacuated. The loculations were broken up and the overlying skin was debrided to healthy tissue.
With this information, we billed an I&D only- no debridement (bundled).
Our physician is questioning why this would not be unbundled with a 59 modifier. I say there is not enough info to verify the unbundling. It is the same anatomical site and there was no separate incision made. Am I correct or should I unbundle and refile?
Opnote states:
The area was aspirated percutaneously. An incision was made and the abscess cavity was entered. Pus was evacuated. The loculations were broken up and the overlying skin was debrided to healthy tissue.
With this information, we billed an I&D only- no debridement (bundled).
Our physician is questioning why this would not be unbundled with a 59 modifier. I say there is not enough info to verify the unbundling. It is the same anatomical site and there was no separate incision made. Am I correct or should I unbundle and refile?