Tip: How to Code a Simple or Complicated Superficial I&D of an Abscess

How do you determine if a superficial I&D of an abscess is simple or complicated? During an incision and drainage (I&D), the provider makes an incision over the abscess into the abscess cavity and allows it to drain. It may be left open allowing the continuation of drainage, loculations may be broken up using a surgical clamp, and/or the wound may be packed with gauze.

Incision and drainage of a superficial skin abscess is coded with one of two codes.

• 10060 Incision and drainage of abscess; simple of single
• 10061 Incision and drainage of abscess; complicated or multiple

The difference between a simple and complicated I&D is, a complicated I&D would contain:

• Multiple incisions
• Drain placements
• Probing to break up loculations
• Extensive packing or
• Subsequent wound closure

CPT® Assistant (April 2010) states, “an incision must be performed and documented to bill for this procedure. If the provider uses a needle to puncture the abscess, and lets it drain, it is not appropriate to use the incision and drainage codes. This procedure would be included in the Evaluation and Management of the patient for the day and not separately reported. It also would be inappropriate to report a puncture aspiration of an abscess 10160 since no aspiration is performed.”

Unfortunately, there isn’t any guidance in the guidelines or from the AMA in the form of a CPT® assist to help determine simple versus complicated. Communication is the key to ensure you are not under coding with the superficial abscess codes. Make sure you educate your provider with documentation tips. The provider needs to document if the abscess is superficial or deep. You also need to know the location because if the abscess is deep, code choice is based on the location of the abscess and is not dependent simply on single versus multiple, and simple versus complicated. Appearance and signs and symptoms can assist with determining simple versus complex. Make sure your provider documents the details needed to support the service that is provided. All providers are frustrated daily with the amount of “additional documentation” needed to support coding. Remind your providers it is not about the quantity, but the quality of the documentation.

Tip: If an I&D is performed deeper than the superficial skin, refer to the codes in the system where the abscess is located. For example, an incision and drainage of a deep abscess on the thigh refer to CPT® code 27301 or incision and drainage of a vulva abscess refer to CPT® code 56405.

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Angela Clements

Physician Coding Auditor, Educator & Consultant at Medkoder

Angela is a Physician Coding Auditor, Educator& Consultant at Medkoder. She has over 18 years of experience in the healthcare industry. Clements serves on the AAPC NAB as the Member Relations Officer and served as Region 5 Representative from 2013-2015. She is a frequent speaker at local medical managers' meetings and local chapters in her region.

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