mardi 26 mai 2015

Wound culture obtained

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.



Wound culture obtained

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