Avoid Common I&D Mishaps

Choose codes wisely because the wrong code may equal lost revenue or an audit.

By Sarah W. Sebikari, MHA, CPC

Incision and drainage (I&D) is a minor surgical procedure that usually can be performed in the office setting by a physician, nurse practitioner (NP), or physician assistant (PA). I&D is a common procedure for an abscess or cyst that may contain pus/purulence. It is performed by first locally anesthetizing the area surrounding the abscess. A scalpel or needle is then inserted into the skin and the purulence is drained.

Surgery-2

CPT® classifies I&D in different sections of the book based on anatomic site. Among the most common codes/categories are:

  • abscesses, 10060-10061
  • cysts, 10080-10081
  • hematoma, 10140
  • complex wounds, 10180

Under-coding I&Ds may lead to revenue loss, while over-coding can trigger an audit. To code I&Ds appropriately, follow three simple steps:

1. Identify the I&D Site

Proper identification of the site requires the coder to be familiar with anatomy.

2. Identify the Abscess, Cyst, Hematoma, or Seroma

An abscess contains pus and is usually left to drain. A cyst is removed together with its epithelial lining. Hematoma is a collection of blood outside a blood vessel. A seroma is a collection of serum in the body, producing a tumor like mass.

3. Differentiate Between Simple and Complicated I&D

Some I&D procedures in the CPT® book are identified as either “simple” or “complicated.” For example:

10080                  Incision and drainage of pilonidal cyst; simple

10081                                    complicated

It is important for physicians to document precisely and differentiate whether a simple or complicated procedure was performed. A simple I&D includes drainage of the pus or purulence from the cyst or abscess. The physician leaves the incision open to drain on its own, allowing for healing with normal wound care. A complex I&D includes placement of a drainage tube to allow for continuous drainage or packing to facilitate healing. In certain cases, tissue excision, primary closure, and/or Z-plasty may be required.

Examples Light the Way to Proper Coding

When coding, it’s important to identify the correct section to use in CPT®. The following examples show that it is easy to consider coding only from the integumentary system using procedures codes 10060-10180, yet the procedure may be more appropriately described in a different section.

The examples below are true scenarios where the coder/physician has inappropriately assigned the wrong procedure code. As you will see, the difference in reimbursement may be minimal on an individual basis, but the impact is tremendous when the error is repeated multiple times.

Example Aook

A patient with an infected right eyelid abscess, swollen and tender, is examined. After informed consent, the area is injected with 0.2 cc of 2 percent Lidocaine. An incision is made with a No. 18 needle to allow good drainage. The patient is given ciprofloxacin for postoperative measure. In this case, 67700 Blepharotomy, drainage of abscess, eyelid appropriately represents the procedure, although the coder had chosen 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single.

CPT® code Fully Implemented
RVU
Medicare
Reimbursement
67700 7.45 $253.12
10060 3.33 $108.72
Difference 4.12 $144.40

 

Note that the relative value units (RVUs) are higher for the correct code (67700) than for 10060: $144.40 is a substantial amount to lose if this is a frequently-performed procedure. Hypothetically, if a provider performs 10 of these procedures every month, a total of $1,444 is lost on a monthly basis for one procedure, and $17,328 is lost annually. In practices where physician salary is based on the number of patients seen or procedures performed, under-coding would reduce the physician’s income considerably.

Note: All Medicare reimbursement rates are copyright 2011 by Ingenix OptumInsight. RVUs are as per the Center for Medicare & Medicaid Services’ (CMS) 2011 National Physician Fee Schedule Relative Value File.

Example B

After receiving a signed, informed consent by the guardian, a 12-year-old boy undergoes I&D of an infected hematoma in the right external ear canal. Following adequate anesthesia of the overlying hematoma’s skin, a No. 15 blade is used to make an incision into the hematoma and express purulence. Patient tolerates the procedure well and is instructed to continue with an antibiotic and follow up within a week.

In this case, the correct code is 69000 Drainage external ear, abscess or hematoma; simple. The coder instead chose 10060, which would lead to lost revenue.

CPT® code Fully Implemented RVU Medicare
Reimbursement
69000 5.50 $182.45
10060 3.33 $108.72
Difference 2.17 $73.73

 

If the physician had documented that a drain or packing was placed or applied to the area, it would be appropriate to code 69005 Drainage external ear, abscess or hematoma; complicated. The difference in revenue is shown here:

CPT® code Fully Implemented RVU Medicare
Reimbursement
69005 6.43 $213.37
10061 5.49 $181.43
Difference 0.94 $31.94

 

Example C

A patient with an infected Bartholin’s cyst undergoes I&D after appropriate prepping and anesthesia is performed. The area is packed with Betadine gauze and sutured in place. The patient is placed on doxycycline. The appropriate CPT® is 56420 Incision and drainage of Bartholin’s gland abscess. Note that placement of drain is included in the procedure and not separately coded. There is no separate procedure code for a complex I&D of Bartholin’s cyst.

CPT® code Fully Implemented RVU Medicare
Reimbursement
56420 3.55 $124.35
10060 3.33 $108.72
Difference 0.22 $15.63

 

Reporting 10060 incorrectly in this case would lead to lost revenue. Although a difference of $15.63 may seem negligible, if the provider performs this procedure on a daily basis, over time the impact will be enormous.

Communicate for Success

The significance of communication between the provider and codercannot be ignored. When documentation is not clear and precise, always clarify with the rendering physician before choosing a code. Educating the physicians on proper documentation will save the practice from unnecessary appeal process, amending documentation, and rebilling. It will also help you pick the accurate code for appropriate reimbursement. Physicians are usually focused on the clinical aspect of providing care and many times are unaware of the confusion improper documentation may cause. Keeping open lines of communication through education, and tying documentation to quality of care, may help them understand its significance.

Sidebar

… it is easy to consider coding only from the integumentary system using procedures codes 10060-10180, yet the procedure may be more appropriately described in a different section.

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Sarah W. Sebikari, MHA, CPC, is senior coding analyst with Premier Health Care Exchange, a health care cost management company. She has been in the health care field for nine years, and a certified coder for seven years, with experience spanning from multiple-specialty physician to outpatient coding and reimbursement.

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2 Responses to “Avoid Common I&D Mishaps”

  1. Vincent says:

    Is there revenue lost if you Bill 10060 when you should have billed for 10061 if the abscess was complex?

  2. jessica says:

    can i bill for the numbing medication with 10061

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