Please help

jenniferan@mcmc.net

　We had a patient that was admitted with severe hypocalcemia and acute renal failure. She also had a chronically draining cyst/abscess in her left groin.  The physician performed this procedure at the bedside "Area of the left groin prepped with Betadine. 　Clean procedure technique used. 　Eleven blade scalpel used to make 1.5 centimeter superficial incision. 　0.5 mL of curd-like material with thin-walled cyst removed. 　Some of the cyst wall was extremely adherent and not all of this could be removed. 　The wound was packed with quarter-inch sterile gauze and dressed with a 4 x 4. Hemostasis was obtained. 　EBL 3 mL." . The coder has coded drainage of the perineum skin, external approach which takes the DRG to 987 non extensive OR procedure unrelated to principle diagnosis and pays $30,706.50. I think it should be coded to drainage of the left upper skin, external approach and pays $9,695.34. I have placed the DRG at 683.

The coder states "The fact that the incision was “superficial”, and the fact that this procedure was not done in the OR, would not exclude the coding of the procedure.    Unfortunately, it does group to DRG 987." Is this correct?

Thank you

Jennifer

jozog@cayugamed.org

I agree with the coder based on the documentation. But probably would have queried the provider for the depth of the incision. The fact that the wound was deep enough to be packed was a clue that this was deeper than the skin. I may have also about trying to capture the attempt to excise the cyst wall.

lprescott1

I would query the provider to clarify the depth of incision and the specific tissue removed. i dont feel the description is clear. 

bbogda@morrishospital.org

If it is an abscess in the groin,  wouldn't you code to inguinal vs perineum skin or left upper skin?  Perineum doesn't sound right for groin to me.

lprescott1

The groin is the location- we need to understand the depth of the procedure- drainage of the skin?  SubQ or Fascia? muscle? that will get you to the right code and you with the documentation above that is not clear.