Wiki Wound culture obtained

[tag60]

I'm unsure how to code this pediatric outpatient office visit. Note as follows.

"Pt presents with right index finger infection x3 days. Pt has swelling of the area under the right 2nd fingernail. Father notes patient constantly bites his fingernails and noticed a soft area underneath the nail, and pt with some pain, so he brought him in.

Exam: FROM x4. Some erythema, swelling, warmth, tenderness below right 2nd fingernail. Some dried blood present. No induration, positive softness.

Needle incision and drainage done. Wound culture sent and will follow up result. Keflex prescribed.

Diagnosis: Cellulitis, 682.9"

I'm unsure whether to code for I&D procedure, 26010 (Drainage of finger abscess, simple...cutaneous tissue of finger)? I guess I'm just unsure if what doctor describes above really fits I&D procedure.

Or is doctor's diagnosis (cellulitis) what I pick up along with E/M code? Would obtaining this wound culture as described (which is minimal, to be sure) be included in E/M visit and that's how to code this visit?

Thanks in advance! Any help or insight is very much appreciated.

 

[mitchellde]

First I would not use the 681.9 code since there is a code for finger. And a needle puncture is not the same as an I&D so I would include that as a part of the E&M.

 

[tag60]

Followup question

Thank you for your help!

I have a similar question I could use some input on. This is for a different encounter but has to do with I&D. This time there is more description. Please see below:

Mother brings child in with two complaints:
1. Concern of a heart murmur. Was told to get a referral to cardiology, so seeking that today.
2. Child has sore on hand.

Exam: CV is examined, murmur noted.
Skin, left hand: Fluctuant, purulent mass with central blood trapped. Tender to palpation, tense.

A/P:
1. Heart murmur. Referral made.
2. Carbuncle, 680.9. I&D done. (See description below.)

Procedure note: I&D of left abscess, superficial. Cleaned with iodine prep, 3 mm incision made, immediate release of purulent drainage, collected for culture. Minimal bleeding. Antibiotic ointment and bandage applied. Wrote for prescription as well.

Is this a true I&D procedure? It seems so to me.

If so, I would code:
680.9, 10060
785.2 -- Do I code an E/M visit for this separate problem (with modifier 25)? Or is this a minor problem included in the charge for 10060?

Or do I code just an E/M visit, and that includes the 10060?

I get confused about knowing when procedures are all that need to be picked up because they include the work done (HPI, exam, MDM).

Thanks in advance!