Orthopedic Coding Alert

Coding for incision & drainage relies on treatment depth.

If your orthopedist has to perform an incision and drainage (I&D) for a patient, then you’ll need to be ready to go with coding smarts for the claim.

The basics: I&D coding is broken into simple and complicated, and knowing the difference could make or break your claim.

We’ve asked some experts for their takes on the ins and outs of I&D coding; here’s what they had to say.

Top 3 Skin Layers Mark Simple I&D

CPT^® indicates that for simple or single I&D procedures, you should report 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single), confirms Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

“Single or simple” in the 10060 descriptor “refers to wounds that primarily involve the ‘surface’ layers of the skin — epidermis, dermis, or subcutaneous tissues; whereas the deeper wounds involve the ‘deeper’ layers of the subcutaneous tissues,” she explains.

According to CPT® Assistant, “the choice of [I&D] code is at the physician’s discretion, based on the level of difficulty involved in the incision and drainage procedure.”

Best bet: You should consult with the performing provider before deciding the level of repair to report for an I&D, if it isn’t spelled out in the notes. Here’s a few examples of lower-level, 10060-type I&Ds:

“For simple [I&D], I look for a single I&D and/or one that required a low level of difficulty,” says Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Oklahoma.

As simple or single I&Ds are characterized by “surface” repair, “the more complicated [I&D] abscesses are larger and may require probing to break up loculations and generally require packing,” according to Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, CPC, CPMA, CAC, CCS-P, CHC, chief executive officer of Edelberg+Associates in Baton Rouge, Louisiana. In most cases, both I&D types require antibiotic therapy, Edelberg confirms.

Example: An established patient with a history of left shoulder surgeries presents with a painful axillary mass that is red, warm, and tender. The physician decides to perform an I&D after a level-three evaluation and management (E/M) service. He numbs the area surrounding the abscess, covers the abscess with antiseptic, and drapes the site. He then opens and drains the abscess, which requires light packing to minimize bleeding.

The orthopedist then covers the site with a bandage, and the wound is left to heal on its own with wound care.

In this scenario, the provider performed a simple, single I&D. On the claim, you’d report 10060 for the I&D and 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) for the E/M.

Remember to append modifier 25 ((Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to show the payer that the E/M was separate and significantly identifiable from the procedure.

Do Deep Dive for Details on Complicated I&D

The difference between a 10060 service and 10061(… complicated or multiple) could depend on a number of factors, according to Pohlig.

“A ‘complicated’ I&D can often be substantiated when multiple incisions are required, or the abscess is complicated by:

• “the presence of an infection;
• “unusual length of time to perform I&D (15 minutes average for 10060 versus about 30 minutes for 10061); or
• “depth of I&D — requiring drain placement, more extensive packing, or subsequent wound closure).”

Coder alert: Surgeons of all stripes perform more complicated I&Ds than your average provider, so be on the lookout for a complicated/multiple I&D when you’re coding.

Consider this example from Satkus: A patient presents with complaints of painful bump on his right leg, right buttock, and left groin. The area hurts when he touches it and the leg area was draining this morning. He put a warm compress on it last night, with no change in appearance.

The provider spots a large subcutaneous abscess on the patient’s right leg that is draining pus. The right buttock and left groin each have an area of bumps that are painful to the patient when touched, and both are draining pus.

The provider injects anesthesia and preps the patient’s right leg. She then incises the abscess with a #11 blade and drains large amounts of pus. The wound drains 3 cc of fluid and the abscess continues to drain, so the provider packs the area with gauze.

She then incises the right buttock and collects 1 cc of fluid, followed by incision and collection of 0.5 cc of “foul-smelling liquid” from the left groin.

In this example, you’d report 10061 for the I&D with diagnosis codes L02.415 (Cutaneous abscess of right lower limb) and L73.2 (Hidradenitis suppurativa) appended to prove medical necessity.