tci General Surgery Coding Alert - 2016 Issue 8

Reader Question: You Decide -- E/M or I&D?

Question: Our surgeon evaluated a 56-year-old male patient with complaints of pain and swelling in the area of the second toe on the left foot. The surgeon documented that the pain started about two days ago, and that 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 appeared to be filled with pus. He numbed the area with a local anesthetic, and then performed a single incision using a No. 11 scalpel blade. He then drained the pus and then probed...

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