tci General Surgery Coding Alert - 2005 Issue 11

READER QUESTIONS: Report Either I & D or Excision

Question: A patient had an existing diagnosis of sebaceous cyst, benign, in cheek. The doctor opens the site with an incision and drains 2-3 cc of pus-filled material. He then removes the sebaceous material and as much of the glandular wall as he can. He takes a biopsy and submits the specimen to pathology. The lab finds the diagnosis is consistent with keratinous cyst. The physician's documentation says: 1. Removal of sebaceous cyst, 2.0 cm L cheek; 2. Abscess drained; 3. Wound packed with Iodoform. Should I bill an excision in addition to an incision and drainage (I&...

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