Orthopedic Coding Alert

Question: I have an operative note that reads: “drained deep infection pocket, R shoulder. Treated pocket to address infection.” What procedure code best represents this service?

Ohio Subscriber

Answer: You can best represent this procedure with 23030 (Incision and drainage, shoulder area; deep abscess or hematoma) — provided you can prove in the notes that the infection was a deep abscess. During this procedure, “the provider incises and drains a pocket of infection or blood deep in the shoulder area, to relieve pain and pressure and or treat infection,” according to Codify.

Clinical actions: Here’s a rundown of what typically occurs during a 23030 encounter, so you can reference it when trying to decide which code to select:

• Provider makes midline incision over the abscess.
• Provider dissects down to the deep fascia.
• Provider drains fluid.
• Provider decides whether to submit a specimen to a laboratory for analysis.
• Provider irrigates area with antibiotics.
• Provider checks for bleeding.
• Provider removes any instruments.
• Provider closes the incision.

Another option: If you cannot prove that the provider performed incision and drainage (I&D) on a deep abscess, consider 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) or 10061 (… complicated or multiple) for this encounter.