tci ED Coding & Reimbursement Alert - 2010 Issue 6

Reader Questions: Make Separate Nature Clear, Give I&D -- E/M Claims Wings

Question:A patient reports to the ED with a cyst in the mucosal tissue of her left cheek. The ED physician performs a level-two E/M service, diagnoses an intra oral hematoma, and then uses a scalpel to cut a tiny slit in the wound to drain it; the wound is not infected. Can I report a separate code for the incision and drainage (I&D) of the hematoma, or is it part of the E/M?Nevada SubscriberAnswer:As long as the notes prove a significant, separately identifiable E/M service, then both the ED E/M and the I&D should stand up...

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