ED Coding and Reimbursement Alert

You'll get twice the payment when you know where to look.

Summer brings an influx of patients to the ED with septic bites, burns, blisters, and skin allergies that may require your ED physician's incision and drainage (I&D) services. I&D is covered for treating abscesses -- but recouping the maximum reimbursement is not as easy as you think. One wrong move could cost you as much as $67 in reimbursement.

Don't let these two myths ruin your I&D abscess coding strategies.

Myth 1: I&D Codes Do Not Differ Significantly From Each Other

Reality: In fact, you'll discover just the opposite: these codes differ in a variety of ways.

For instance, complicated I&D code 10061 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple) pays almost twice the reimbursement that superficial I&D code 10060 (...simple or single) does.

You'd be able to tell superficial from complicated with wounds that primarily involve the 'surface' layers of the skin " the epidermis, dermis, or subcutaneous tissues, according to Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Example: A patient with an upper arm mass that is red, warm, and tender comes to the ED. The physician performs a level-two E/M, and decides to do an I&D. She numbs the area surrounding the injury, covers the abscess with antiseptic and drapes the site. She then opens and drains the abscess, covering the site with a bandage and leaving it to heal on its own with wound care.

This procedure qualifies as a simple (superficial) I&D, which you should report with the following codes: 10060 for the I&D; 99282 ( Emergency Department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity) for the E/M; modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached to 99282 to show that the I&D and E/M were separate services; and 682.3 (Other cellulitis and abscess; upper arm and forearm) representing the abscess, and as diagnosis for 10060 and 99282.

Report 10061 If Documentation Specifies Infection

Although you may think determining when to report complicated I&D will be difficult, rest assured: it's easy. Look for these two elements: multiple incisions are required, or the abscess is complicated by the presence of an infection, says Pohlig.

You could also turn to 10061 if the I&D takes an unusual length of time to finish, is especially deep, or requires drain placement, packing, placement of wicking material or subsequent wound closure.

Example: The ED physician performs I&D on a patient with an infected forearm abscess. She incises to just above the cyst cavity and drains about 10 ml of foul-smelling pus. She removes the pus, and then excises the cyst wall from the surrounding tissue using electrocautery. She irrigates the wound with saline and places packing in the cavity.

Way out: This procedure falls under complicated I&D. On the claim, you should report 10061 for the I&D, and 682.3 (Cellulitis abscess upper arm and forearm) linked to 10061 to represent the patient's cyst.

Payoff: You must know how to differentiate between the two I&D codes, or else you risk losing out on your reimbursement. Based on 2010 RVUs " 2.41 for 10060 and 4.24 [facility] for 10061 -- the difference in payment is significantly high. Using the conversion factor of $36.8729, 10060 should pay about $88.86, while 10061 about $156.34.

Myth 2: Use I&D Codes Whenever Abscess Is Present

Reality: The presence of an abscess or cyst does not always require a surgical incision and drainage service. When pus is present in an abscess or cyst without a drainage outlet, then it is medically necessary to perform an incision and drainage.

Caution: You are likely to get denied on your claims for I&D services if the physician performs the procedure for drainage of a blister, particularly if the blister is small, uninfected, superficial and uncomplicated, according to healthcare reimbursement site AccuChecker.

Remember: Your physician's notes will need to support the complexity of the procedure, reminds Elizabeth McDonald, CPC, coding specialist in the department of surgery at UPMC-Pittsburgh. If blisters, cysts (including sebaceous cyst), cellulitis or other fluid collections and infections do not have documented presence of discrete abscess or pus collection, forget about reporting 10060-10061.

Note: When you code these procedures in conjunction with an E/M service such as 99283 ED E/M level three visit, make sure you append modifier 25 to the E/M to point out that you are seeing the patient for multiple ongoing conditions.