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Thread: Excision of an Abscess?

  1. #1
    Join Date
    Apr 2007
    Location
    Albany, GA
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    Default Excision of an Abscess?

    One of my providers often dictates, "Incision and Drainage, Excixion, and Debridement of an Abscess." In the Op Note, he does describe the excision process, but I am a little unsure of which code(s) to use. Should I code and I&D CPT code with the abscess ICD-9, en excision CPT with a lesion or unspecified skin disorder ICD-9, or some combination of these?

  2. #2

    Default

    Hi,
    What is your diagnosis?


    Nalini CPC

  3. #3

    Default

    Quote Originally Posted by hunter1 View Post
    One of my providers often dictates, "Incision and Drainage, Excixion, and Debridement of an Abscess." In the Op Note, he does describe the excision process, but I am a little unsure of which code(s) to use. Should I code and I&D CPT code with the abscess ICD-9, en excision CPT with a lesion or unspecified skin disorder ICD-9, or some combination of these?
    Need a lot more information. Where was the abscess, how was it performed? Please place a scrubbed note so we can tell you what needs to be coded.

  4. #4
    Join Date
    Apr 2007
    Location
    Albany, GA
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    Default Op Note

    Pre-op Dx: Abscess of Upper Lip
    Post-Op Dx: Same

    Procedure Performed: Incision & Drainage, debridement, and excision of necrotic tissue

    Anesthesia: General

    History: This patient developed an abscess on the upper lip, measuring about 3 cm. in diameter with necrosis in the center with puffiness and redness. Seen in the ER and admitted for surgical intervention.

    Procedure: Under general anesthesia with endotracheal tube, after successful induction, usual Betadine prepping and draping was carried out. Incision and drainage was done, large amounts of purulent drainage was noted. A culture and sensitivity test was obtained and after which all the necrosis was debrided and the necrotic tissue on the center was excised. After this was done all the loculated area was broken in and all the purulent drainage was drained. The wound was irrigated with antibiotic solution. Xeroform gauza and sterile dressing applied. The patient tolerated the procedure well. Was brought to the recovery room in satisfactory condition.


    I was thinking CPT 10060 with ICD-9 682.0, but I am not sure if this covers everything he did, or if there is a better code to use based on the information given. The surgeon codes other procedures similar to this one, but with other sites on the body. Basically I just need an opinion on if this constitutes I&D, excision, or both.

  5. #5

    Default

    Hi,
    The procedure performed is Incision & Drainage and irrigation and debridement, and excision of necrotic tissue, so you need to code 11042/00300-5 base units..With the abscess diagnosis code..
    Hope this helps..
    Nalini CPC

  6. #6
    Join Date
    Apr 2007
    Location
    Milwaukee WI
    Posts
    4,453

    Default 10061

    I would code this as 10061 - I &D - complicated.

    I do not see documentation to support 11042 or 00300. (Any anesthesia charges would be billed by anesthesiologist, not the surgeon.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 07-27-2011 at 12:18 PM.

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