Dermatology Coding Alert

Know what a comedo extractor is? Read on to find out.

When your dermatologist performs an incision and drainage (I&D) for a patient, the notes will hold the key to your coding choice. If you get the procedure level wrong, you’ll miscode the claim and open the practice to either underpayment or overpayment for services rendered.

Don’t fret: We’ve got the scoop on how to differentiate between different I&Ds your dermatologist might perform. Check out this FAQ before you file your next I&D claim.

Q: What specifics would characterize a “superficial” I&D?

A: If the dermatologist performs simple/single I&D, you’d report it with 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single).

“A simple or single abscess is limited to a small collection of purulent material, such as a paronychia, a small cyst, or the type of pus collection generally found around an infected hair follicle,” explains Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, CEO of Edelberg + Associates in Baton Rouge, La. Consider this example from Edelberg:

A 12-year-old established patient presents complaining of a painful, red, and swollen area around the nail margin on his left ring finger. He can express a small amount of pus. The physician performs an expanded problem focused history, detailed examination and moderate medical decision making.

The physician then performs a digital block with lidocaine 1% and, under sterile fashion, performs a simple I&D of the abscess; she also obtains a culture to identify the type of abscess. After cleaning and bandaging the finger, the physician tells the patient to keep the wound area clean and return if the condition does not resolve in a week or so.

For this encounter, Edelberg says you should report

• 10060 for the I&D
• 87040 (Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates [includes anaerobic culture, if appropriate]) for the culture if your office is performing the complete culture. If you send the sample to an outside lab, you cannot code for collecting the culture sample.
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity…) for the evaluation and management (E/M) service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99214 to show that the E/M service was a significant, separately identifiable service
• L03.022 (Acute lymphangitis of left finger) appended to 10060, 87040, and 99214 to represent the patient’s abscess.

Q: What specifics would characterize a ‘complicated’ I&D?

A: If the dermatologist performs complicated/multiple I&D, you’d report it with 10061 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple).

“The more complicated abscesses are larger and may require probing to break up loculations; they also generally require packing,” explains Edelberg.

Also: Complicated abscesses might occasionally “require sonography to identify the extent of the lesion, particularly when a significant MRSA [Methicillin-resistant Staphylococcus] infection is suspected,” reports Edelberg. A 10061 I&D could also include probing to break up loculations and packing with gauze to keep the wound open for healing, she continues. Consider this example from Edelberg:

A 54-year-old established patient presents to the physician with a painful, red, and swollen “boil” on her left buttock. The physician performs a comprehensive history, a detailed physical examination and moderate MDM. The physician uses lidocaine to numb the area, breaks up the loculations within the cyst cavity, and drains and packs the lesion.

The physician sends the wound drainage to the lab for culture to test for MRSA. The physician advises the patient on wound care and hygiene and instructed to return for a follow-up visit in two days.

For this encounter, Edelberg says you should report:

• 10061 for the I&D
• 87081 (Culture, presumptive, pathogenic organisms, screening only) for the culture if your office is performing the complete culture. If you send the sample to an outside lab, you cannot no code for collecting the culture sample.
• 99214 for the E/M service
• Modifier 25 appended to 99214 to show that the E/M was a separate, significantly identifiable service
• L03.317 (Cellulitis of buttock) appended to 10080, 87081, and 99214 to represent the patient’s wound.

Q: When would a physician perform acne surgery or pilonidal cyst surgery?

A: The dermatologist might perform surgery for some patients suffering from acne, which you’d code with 10040 (Acne surgery [e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules]).

A 10040 service includes “cutting and extracting the contents of more severe acne lesions. Pimples are cut open and drained of their contents,” Edelberg explains. Another 10040 surgery is comedo extraction. “A closed comedo — a whitehead — is more embedded into the skin than an open comedo, or a blackhead,” she continues. In comedo extraction, the physician often uses a comedone extractor to remove the contents. Since whiteheads are more embedded into the skin, they are often require incision before the physician can use the comedo extractor.

Pilonidal cysts: When the dermatologist performs pilonidal cyst surgery, you’ll report 10080 or 10081, depending on encounter specifics. This type of cyst/abscess is small, usually occurring in the cleft at the top of the buttocks. Pilonidal cysts often contain hair, dirt, and/or debris.

When deciding whether a pilonidal cyst procedure is simple or complicated, Edelberg recommends applying the same set of rules that you use for other types of cysts or abscesses. Codes 10080 and 10081 are just more specific to the location of the wound (buttock cleft), Edelberg says.