Significant E/M

Dear friends,

I need clarify the significant E/M in below document,

H&P:

The patient came for gluteal abscess and its seems draining and some pain in the abscess. No nausea, vomiting. ROS is all other systems are negative.

PFSH; Breast cancer

PE:

Cons: normal

ENT-normal

Eyes-normal

Lungs-normal

Cardio-normal

lymp-normal

musculo-some drain in gluteal muscle

GU-normal

A/P:

1.Gluteal abscess- I/D today.

Plan:

1.Ciprofloxacin IV

I&D:Patient tolerated well during excision of abscess

Can anyone explain how the significant E/M is running over here, because one of my superior guide me to give 99203-25, 10060. but my concern is here there is no significant E/M done, I don't want to go with over billing. can any one give some suggestion to this document.

Thanks,

Sathyaraj CPC,CEMC

Significant E/M