Wiki Drainage of Cyst

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ablack74

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I have a document that a provider drained a cyst on but I have a question about the completeness of this record. Can someone help clarify this note and the coding that would undergo this as well.

******Chief Complaint Patient complains of a draining cyst on her left back.

Problem List / Past Medical History
Problem list
Past Medical History
Dermatologic Past Medical History
Other Past Medical History
Implantable Devices

Family History Family History: Mother, Father, Sibling, Other relative.

Physical Examination

Integumentary: Integumentary exam: Drawings ( Posterior skin (Inserted Image.
Unable to display) ).
express contents of cyst, some drainage and sack from the puncta.

Assessment
Draining cyst on the left lower back.

Plan Contents of the sack expressed with sack.

Local wound care return in 6 months.*********

My question is, does the documentation need to specify the drainage was done incisionally?:confused:

Or if this is a complete document and another code can be reported, can someone help with the rational so I can understand this procedure coding better.

Thank you for any and all help!
 
I think you've hit the problem on the head. You can't bill for an "incision and drainage" if all you did was the drainage. If there was an incision, it needs to be documented.

Additionally, if the I&D was for an abscess, our local MAC (Florida) has an LCD that requires the location, size, and appearance to be documented, and that also specifies that the incision MUST be done with a blade. I don't know what other contractors or commercial insurers require.

Finally, be sure you are using the correct CPT code, as this is one that confuses people. Here is the breakdown of the correct CPT code to use:

1. I&D OF ABSCESS #10060-10061

2. I&D OF CYST OR HEMATOMA #10140

3. COMPLEX I&D OF POST-OP WOUND INFECTION, packed open for continuous drainage or closed with a latex drain #10180

4. I&D OF PILONIDAL (?TAILBONE?) CYST #10080-10081

5. PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST#10160(Only to be used if the fluid is aspirated, not drained)

6. I&D OF FOREIGN BODY FROM SUBCUTANEOUS TISSUE, SIMPLE #10120

7. I&D OF FOREIGN BODY FROM SUBCUTANEOUS TISSUE, COMPLICATED #10121
 
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