Pediatric Coding Alert

Avoid costly coding errors by paying attention to answer 4.

The incision and drainage (I&D) codes can really test your understanding of CPT^® terminology, clinical procedures, and anatomy. But armed with the answers to these four frequently asked questions, you can master I&D coding quickly and easily.

That’s a skill that your pediatrician will thank you for the next time they look at their finances. Read on if you want to know why.

What’s the Difference Between Simple/Single I&D and Complicated/Multiple?

CPT^® has divided several I&D codes into pairs designated as either “simple or single” or “complicated or multiple”:

• 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single)
• 10061 (… complicated or multiple)
• 10080 (Incision and drainage of pilonidal cyst; simple)
• 10081 (… complicated)
• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple)
• 10121 (… complicated).

While documentation should make it easy for you to determine if your pediatrician performed one or multiple procedures, from a coding perspective, the definition of simple and complicated is not so clear. The CPT^® manual does not provide definitions for the terms; instead, you should look to guidance found in CPT^® Assistant if you are faced with a choice between codes.

“Per a Q&A that appeared in the December 2006 issue of CPT^® Assistant [Volume 16: Issue 12], CPT^® does not define ‘simple’ or ‘complex’ in this context. Instead, CPT^® Assistant says, ‘the choice of code is at the physician’s discretion, based on the level of difficulty involved in the incision and drainage procedure,’” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

What’s the Difference Between 10140 and 10160?

Another dilemma lies in knowing when to use 10140 (Incision and drainage of hematoma, seroma or fluid collection) or 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst) when your pediatrician removes fluid from a patient’s hematoma. Once again, though, the answer lies in looking carefully at your pediatrician’s documentation, especially in their description of the procedure used.

“In 10140, the physician incises the fluid pocket, bluntly penetrating it to aid fluid evacuation. The pediatrician may also pack the incision or place a drain to let the fluid drain continuously in this procedure,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Puncture aspiration, on the other hand, “typically involves the pediatrician using a large bore needle on a syringe, aspirating the fluid into the syringe, and thus decompressing the fluid space. In this procedure, there is no closure as it involves needle aspiration, and a simple pressure dressing may be placed over the site when the procedure is complete,” Moore notes.

So, What Do I Report When My Pediatrician Simply Punctures an Abscess and it Drains by Itself?

Just as you should not use the hematoma puncture aspiration code when your pediatrician incises and drains a bruise so, too, you should not use 10060/10061 if your pediatrician decides to puncture an abscess and let the fluid drain on its own.

In this instance, however, you will not find an abscess puncture aspiration code among the I&D codes. Instead, you will follow the advice provided in another issue of CPT^® Assistant (Volume 20: Issue 4) which tells you that as your pediatrician has not incised or aspired the abscess, you should “report the appropriate E/M [evaluation and management] services based on the key components provided.”

In this case, with a self-limited or minor problem, and a minimal risk of morbidity from treatment, medical decision making (MDM) would rise to a straightforward level, and you would be able to support reporting 99212 (Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making ...) assuming your patient is established to your practice. The actual E/M level chosen, however, will be dependent on your pediatrician’s level of medical decision making (MDM) or the length of time your pediatrician spends with the patient.

Are 10120/10121 the Only Codes You Can Use for FBRs?

Even though 10120/10121 describe incisions for foreign body removals (FBRs) from the subcutaneous tissue, they should not be your go-to code for FBRs. If your pediatrician’s documentation indicates a deeper FBR located in a specific anatomic area, then you should look to the musculoskeletal section of CPT^® for codes that capture that information. They include:

• 24200-24201 (Removal of foreign body, upper arm or elbow area …)
• 25248 (Exploration with removal of deep foreign body, forearm or wrist)
• 26075 (Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each)
• 26070 (… carpometacarpal joint)
• 27372 (Removal of foreign body, deep, thigh region or knee area)
• 28190-28193 (Removal of foreign body, foot …)

Coding alert: Using the general code for a subcutaneous FBR from the foot rather than the more anatomic-specific FBR code can be an expensive mistake. The 2021 nonfacility fee for 10120 is $42.57, while the fee for 28190 is $70.14 — a difference of $27.57. So, it is vitally important that you work with your pediatrician to ensure that information appears in the medical record.