ED Coding and Reimbursement Alert

Differentiate simple from complicated to nail down the right code.

When your emergency department (ED) provider performs incision and drainage (I&D) services, you deserve to get paid for them — if you’re performing true I&Ds. Unfortunately, many providers are incorrectly reporting incision and drainage codes for services that don’t technically qualify as an I&D.

Check out these five tips to ensure you code and bill properly for your provider’s I&D encounters.

1. Know What’s Covered

The I&D codes are typically payable if you’re resolving abscesses that form under the skin. Some providers report I&D codes for hematoma drainages, cyst incisions, and seroma evaluations. But most insurers won’t typically reimburse you for codes from the 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) through 10081 (Incision and drainage of pilonidal cyst; complicated) range if you addressed cysts, hematomas, or seromas, unless your documentation reflects detailed circumstances regarding why you did this and how.

In black and white: “Since the majority of hematomas, seromas and cysts do not require incision and drainage or aspiration, and since this procedure can actually increase the risk of infection, providers reporting these services must document the size, location and quantity of blood, material or serosanguinous fluid drained, as well as the medical necessity of the procedure, (e.g. severe pain or infection and failure to resolve with conservative measures),” according to the Centers for Medicare & Medicaid Services (CMS).

If your documentation shows that an I&D of a hematoma or cyst was performed but your documentation doesn’t fulfill the requirements outlined above, it’s possible your doctor’s service instead warrants 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst). This service typically involves the provider using a large bore needle on a syringe to aspirate the fluid into the syringe, thus decompressing the fluid space.

2. Differentiate Simple From Complicated

When you’re scanning the coding options for I&D services, you’ll note that some codes describe simple or single procedures, where others refer to more complicated or multiple services. For instance, 10060 is for simple or single I&Ds, while 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple) describes complicated/multiple I&Ds.

In general, a complicated I&D “may require multiple incisions, drain placement, wound packing, or probing to break up loculations within the abscess,” says the American College of Emergency Physicians. A simple I&D, on the other hand, “usually involves a single incision to drain pus and leave the wound open to heal on its own.”

When you’re reviewing the procedure notes, look for documentation indicating how many incisions the provider performed. You can then determine whether a simple or complicated I&D service occurred. You should also evaluate whether the wound was packed, drains were used, or whether the provider needed to probe the abscess.

Simple I&D example: A 67-year-old patient presents to the ED with a carbuncle located in their armpit. They indicate it’s been bothering them for two weeks, but that it recently became warm, inflamed, and sensitive to the touch. The provider makes a single incision into the carbuncle and allows it to drain. They then apply antibacterial medication to the site and advise the patient on how to care for it at home. You would report 10060 for this visit.

Complicated I&D example: A 46-year-old patient presents to the ED with a hidradenitis suppurativa lesion on the fold between their thigh and groin. They said they had been applying warm compresses to get it to drain, but it’s become more painful over time. The physician examines the lesion and determines that although one lesion is visible, the abscess is deep in the skin and attached to two other lesions that put the patient at risk of experiencing “tunneling” if unaddressed. The ED physician makes an incision over the lesion and drains out the abscesses, then uses a probe to clear out the separations between the abscesses. The provider packs the wound with antibacterial packing and refers the patient to see a dermatologist within 48 hours. You would report 10061 for this visit.

3. Document Symptoms, Size, Appearance, and More

Payers are always looking for thorough documentation to support the I&D codes, so it’s important to include as many details as possible about the procedure. When the physician performs I&D, CMS expects providers to include:

• The patient’s signs and symptoms that necessitated the I&D
• The preoperative size, location, and appearance of the lesions that were addressed with I&D
• A description of the procedure, including equipment used, quantity and type of fluid drained (such as serous, sanguinous, bloody, etc.)
• Any conservative measures that were previously used to address the patient’s symptoms

4. Know When to Use Ultrasound Codes

In some instances, ultrasound (US) may be separately billable along with I&D services, but you must be able to document why you needed US to diagnose and locate lesions under the skin. The most appropriate US code will depend on the location.

For instance, if the provider performs I&D on a neck lesion, 76536 (Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation) may be the most appropriate option.

5. Clarify Pilonidal Cyst Differences

If the patient has a pilonidal cyst, which is fluid-filled sac near the tailbone, then your coding options will shift to the following: 10080 (Incision and drainage of pilonidal cyst; simple) or 10081.

In this procedure, the provider performs an incision and extracts the entire cyst. For simple procedures, the wound is left open to heal on its own, and the patient is advised how to care for the wound at home. In complicated cases, the provider will document excising extensive tissue and potentially closing or packing the wound.

Simple example: A 43-year-old patient complains of pain and tenderness at the top of their gluteal cleft. They began experiencing some pain a few days ago, and it has been increasing since then and intensifies when they try to sit down. Upon examination, the physician finds a small, inflamed cyst above the patient’s buttocks. Your physician then preps the patient and makes a stab incision into the cyst, which yields 15 mL of pus. The physician then irrigates the cavity, leaves the wound open, and instructs the patient to schedule a follow-up visit. For this encounter, you’d report 10080.

Complicated example: An 82-year-old patient presents to the ED for extreme pain in their lower back. They say the pain has been present while sitting in their easy chair but not while sleeping. However, this morning the patient felt pain even when lying on their side in bed. They sat in a warm Epsom salt bath, but it didn’t resolve. The physician examines the patient and finds a tender, egg-sized mass that has a small opening with a hair at its center. The doctor incises the mass, which yields 22 mL of thick, blood-tinged pus. The provider excises tissue from the wound and sutures it closed. For this visit, you’ll report 10081.

Torrey Kim, Contributing Writer, Raleigh, NC