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Wiki Coding an Abscess

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krisandrew

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hi there...
I have a few MD's that are questioning the difference between a simple I&D and complicated I&D. The MD's have "heard" that if you pack an abscess, that alone results in billing a complicated I&D.
Any suggestions on where I can find some documentation to present to them for discussion?? Many thanks!
 
As long as the physician feels that it was complicated, for whatever reason, and the documentation supports it -- and actually states complicated because of ..... -- then it's legit.
 
Excerpt from CPT Assistant...

Surgery: Integumentary System

Question: Many of the incision and drainage codes (ie, 10060-10140, 10180) include one code for simple procedures and one code for complicated procedures. Does the CPT code set define these terms?

AMA Comment: No. The choice of code is at the physician's discretion, based on the level of difficulty involved in the incision and drainage procedure.

Coders Desk Reference:
The site is gently cleaned with a disinfectant. An incision is made in the center of the abscess or cyst. The site is drained and irrigated with a sterile solution. Then the skin is then closed for a simple abscess. Depending on the depth of the abscess, the physician may insert a catheter or drain for a few days. Code 10060 for a simple or single procedure; 10061 for complicated or multiple procedures. For a complicated abscess, the site is packed with sterile gauze to help the wound heal and prevent further leakage. Complex abscesses may also require subsequent surgical closure.
 
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