tci General Surgery Coding Alert - 2000 Issue 5

Case Study: Documenting Separate Incisions Can Get Two Procedures Paid

Nugget: Coders can find critical information by carefully reading the body of the surgeon's operative report that allows them to get reimbursed for procedures that may not be listed at the beginning. Although irrigation and drainage (I&D) usually is bundled into the removal of a foreign body, if the two procedures are performed through separate incisions, they may be billed separately as long as both incisions are documented clearly in the operative report. A coder who only reads the top of the following operative report might assume, on seeing the incision and drainage together with the foreign...

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