Stephen is a well-known, 15-year-old patient who presents to Dr. X because of a large painful pimple on his gluteal crest
Expanded problem-focused history and problem-focused physical examination reveal this to be a pilonidal abscess without sinus tract. Low medical decision making recommends a simple incision and drainage of this pilonidal abscess, which has a 10-day global period of surgery. Stephen is prepped, incision and drainage performed without complication. Wound is packed and does not require suturing. Stephen tolerated the procedure well. Which of the following best reflects the performed E/M service and modifier usage? a. Office or other outpatient service; established patient; level 3, modifier 57
b. Office or other outpatient service; new patient; level 2; modifier 25
c. Office or other outpatient service; established patient; level 3; modifier 25
d. No E/M service reportable since only the pilonidal cyst excision should be reported
d) No E/M service reportable since only the pilonidal cyst excision should be reported
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