Urology Coding Alert

Question: My urologist performed a procedure on a patient with a large symptomatic inguinal abscess. The op report reads:

“Patient was positioned in the supine position and prepped and draped in standard sterile fashion. Incision was made along the right inguinal crease, ~ 5cm in length. Culture of fluid obtained. Large volume of purulent fluid was expressed. Using blunt dissection loculations were then broken up and more pus expressed. Care was taken to avoid proximal dissection to try and reduce chance of peritoneal communication. Once abscess was felt to be completely drained several 4’0 vicryl stitches as well as electrocautery was used to achieve hemostasis. Once hemostasis was achieved irrigation was performed with 2L of GU irrigant with Cystec pulse irrigator. Following this, wound was packed with damp kerlex.”

How should I report this procedure?

Iowa Subscriber

Answer: You should report 10061 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple) for this procedure.

Pointer: When reporting this type of procedure, you need to decide between 10060 (... simple or single) and 10061. The presence of multiple loculations and the large size of the abscess in this case indicate the complicated nature of this pathology and support reporting 10061.