tci ED Coding & Reimbursement Alert - 2009 Issue 12

You Be the Coder: Cyst Drainage Vs. Cyst Removal

Question: I need some help with the following operative note: "Px with CC: growth, right cheek Exam shows cyst full of purulent yellow pus Dx: seborrheic keratosis Drained wound w/scalpel, saline irrigation, probed to break up loculations, septae broken down, curetted, and packed with gauze. Sent specimen to lab." We just got the lab results back, and the sample was negative for neoplasms. How do I code this encounter? Is this a biopsy or a separate service? Tennessee Subscriber Answer: Your physician performed an incision and drainage (I&D) of a sebaceous cyst with pathology. "Seborrheic keratosis" is...

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