tci E/M Coding Alert - 2015 Issue 10

You Be the Coder: I&D + E/M = 2 Codes

Question: Our physician reviewed a 56-year-old male patient with complaints of pain and swelling in the area of the second toe on the left leg. He documented that the pain started about two days ago, and the patient didn’t remember any injury to the area. Upon examination, the physician noted an approximately 2 cm swelling in the area of the toe that appears to be filled with pus. He numbed the area with a local anesthetic, then performed a single incision using a No. 11 scalpel blade. He then drained the pus and then probed into the area...

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