AHA Coding Clinic® for HCPCS - 2017 Issue 2; Ask the Editor
Complicated incision and drainage
A patient underwent an incision and drainage procedure at our facility. According to the operative report, an incision was made over the lesion and purulent material was expressed. Loculations were broken up using forceps and more of the material was expressed. The drainage cavity was then irrigated, packed and dressed with sterile gauze. Would it be appropriate to code an incision and drainage (I&D) as complicated based on documentation that a drain or packing was used? There are many articles available that provide varying opinions and we would appreciate an official response. Should the term complicated be documented or may the coder use the drain or packing as an indicator of a complicated procedure? ...
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Article Overview
This article discusses a documentation question about incision and drainage procedures and whether certain operative details are enough to support reporting the procedure as complicated. It is aimed at coders and coding staff who need guidance on interpreting operative reports and determining when physician clarification is appropriate. The article covers general coding documentation expectations and the type of official response provided in this scenario.
Why This Topic Matters
Accurate reporting of incision and drainage procedures depends on the medical record supporting the level of service documented. This topic matters because it helps coding professionals avoid unsupported code selection and know when to seek clarification.
What You Will Learn
- How documentation is evaluated for incision and drainage procedure reporting
- When physician clarification may be needed for incomplete or unclear operative documentation
- What general documentation considerations apply to determining procedure complexity
- How coding staff should think about operative report details in the context of procedure selection
Who Should Read This
- Medical coders
- Coding auditors
- Physician documentation improvement staff
- Revenue cycle professionals
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