# Documentation Requirements for I&D



## CatchTheWind (Oct 8, 2013)

When coding for I&D (10060 or 10061), our LCD (Florida) says the provider must document the presence of a symptomatic (e.g. inflamed, painful, tender) abscess* and its location, size, and appearance.  That's all (except that if the procedure is performed repeatedly, there must also be a statement of the "reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence.")

But I came across an article** that says the record must also document that a Culture & Sensitivity of the puss was sent out, that the patient was instructed to use astringent soaps, and that a prescription for topical or oral antibiotic was given. (It also states that for complicated cases, use of local anesthesia and prescription for oral antibiotic must be documented.) Is anyone familiar with these "requirements," and do you know whether they are truly legitimate?


*furuncle, carbuncle, suppurative hidradenitis, abscessed cyst, abscessed paronychia, or other abscess involving the cutaneous and/or subcutaneous structures


**article by Dermatology Practice Solutions (http://dermatologymedicalbilling.com/dermatology-coding/incision-drainage-coding//) with source given as "The 2009 Podiatry Manual" by Dan Bluth, DPM.


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