CODING GUIDANCE-INCISION AND DRAINAGE OF ABSCESS

CODING GUIDANCE-INCISION AND DRAINAGE OF ABSCESS

While the code descriptions reference single versus multiple, per the CPT Assistant, December 2006, Surgery: Integumentary System the Provider is the individual who determines whether the I&D is simple or complex if only one subcutaneous abscess was incised/drained.

For single subcutaneous abscesses, the presence or absence of packing does not clarify that the single abscess is “complicated” – the Provider will need to document if it is simple or complicated before 10061 can be assigned to a single subcutaneous abscess.

• Without the Provider documentation that the single subcutaneous abscess is “complicated”, the correct code assignment is 10060.

Simple I&D of multiple subcutaneous lesions would be coded to 10061 (see also CPT Assistant 2005, p. 7, Incision and Drainage Abscess)

 

CPT 10060 –

• Incision and drainage of abscess, carbuncle, suppurative hidranenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia – simple or single). One superficial abscess, or a single larger abscess.

CPT 10061 - Incision and drainage of abscess, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia; complicated or multiple. I&D of multiple abscess (simple, complicated or not specified). (See CPT Assistant, Aug 2017 – Surgery: Integumentary System & 2nd Q 2011 Coding Clinic for HCPCS -Incision and Drainage of Multiple Abscesses)

• I&D of complicated abscess (single or multiple) that is larger and requires probing to break up loculations or involves packing. Spider bites tend to be larger, more complicated lesions that when incised and drained. (See 2^nd Q 2017 Coding Clinic for HCPCS.

Complicated Incision and Drainage Coding Clinic for HCPCS, Second Quarter 2017: Page 4 Coding advice contained in this issue is effective with procedures/services provided after August 11, 2017, unless otherwise noted.

QUESTION 8 - A patient underwent an incision and drainage procedure at our facility. According to the operative report, an incision was made over the lesion and purulent material was expressed. Loculations were broken up using forceps and more of the material was expressed. The drainage cavity was then irrigated, packed and dressed with sterile gauze. 

Would it be appropriate to code an incision and drainage (I&D) as complicated based on documentation that a drain or packing was used? There are many articles available that provide varying opinions and we would appreciate an official response. Should the term complicated be documented or may the coder use the drain or packing as an indicator of a complicated procedure?

ANSWER No, it would be inappropriate for the coder to assume that the incision and drainage is complicated based on the use of a drain or packing without confirmation from the physician. When the documentation is unclear the coder should query the physician for clarification.  

Surgery: Integumentary System CPT Assistant, August 2017, Volume 27, Issue 8, page 9

Question: How should the Current Procedural Terminology (CPT^®) code 10030, Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous, be reported, ie, must the drainage catheter be left in place in order to report code 10030?

Answer: In order to report code 10030, the drainage catheter needs to be left in place and secured with a suture or alternative fixation device for post-procedure evacuation, and the patient sent to recovery. If a drain was not left in place for prolonged drainage, the procedure would be reported as an aspiration with code 10160, Puncture aspiration of abscess, hematoma, bulla, or cyst, rather than an abscess drainage.

Incision and Drainage of Multiple Abscesses Coding Clinic for HCPCS, Second Quarter 2011 Page: 8 Coding advice contained in this issue is effective with procedures/services provided after July 30, 2011 unless otherwise noted.

 

Question #8 - Patient presents to the emergency department for incision and drainage (I&D) of multiple abscesses. Purulent fluid was drained from the abscesses of the left quadriceps and the left lower quadrant, a moderate amount of fluid was drained from another area of the left lower quadrant and packed with iodoform gauze, and a small amount of fluid was drained from the left trapezius and packed with iodoform gauze. What is the correct code assignment for the I&D of these multiple abscesses? Would our facility report CPT code 10060 for each abscess drained? Or would we report 10061 once for all of the abscesses which were drained?

 

Answer - Assign CPT code 10061, Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple, for I&D of the multiple abscesses. It would be inappropriate to assign 10060, Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single, for each abscess. 

Surgery: Integumentary System CPT Assistant April 2010, Volume 20, Issue 9, page 10

      

Question: Would it be correct to report CPT code 10060, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single, when a physician uses a needle to puncture an abscess that is allowed to drain by itself, without any incision or aspiration of the abscess into the syringe?

 

Answer: No. CPT code 10060, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single, includes both the incision and drainage of an abscess, therefore, it would not be appropriate to report this code because there was no incision involved.

Also, it would be inappropriate to report code 10160 (puncture aspiration of an abscess) since no aspiration was performed. If evaluation and management (E/M) services were rendered, such as services described in code 99211, this would be used to report the service. Report the appropriate E/M services based on the key components provided.

Surgery: Integumentary System CPT Assistant, December 2006, Volume 16, Issue 12, pages 14 - 15

 

Question: Many of the incision and drainage codes (ie, 10060-10140, 10180) include one code for simple procedures and one code for complicated procedures. Does the CPT code set define these terms?

 

AMA Comment: No. The choice of code is at the physician's discretion, based on the level of difficulty involved in the incision and drainage procedure.

Incision and Drainage Abscess CPT Assistant, Special Issue 2005,  page 7

 

Question: If an incision and drainage is performed for one abscess on the arm and one on the leg, would it be appropriate to report code 10060 two times? Or should code 10061 be reported one time?

 

AMA Comment: Many of the incision and drainage (I & D) procedures include one code for simple procedures and one code for complicated procedures; however, the terms simple and complicated are not defined in the CPT codebook.

Rather, the choice of code is at the physician's discretion, based on the level of difficulty involved in the incision and drainage procedure. It is important to note that code 10060, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single, should be reported for a simple or single I & D procedure.

 

Code 10061, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple, should be reported for a complicated or multiple I & D procedure.  

CODING TIP: Therefore, if simple I & D procedures are performed on multiple lesions, then the appropriate code is 10061.