Dermatology Coding Alert

Question: An established patient reports to the dermatologist complaining of sores on his lower back and upper abdomen. The dermatologist performs a detailed history and expanded problem focused exam, and diagnoses cutaneous abscesses of the abdominal wall and back. Notes indicate moderate medical decision making (MDM). There is also a note stating: “Meth-susceptible Staph underlying cause.” How should I report this encounter?

Alaska Subscriber

Answer: To report this encounter correctly, you’ll need a trio of ICD-10 codes along with your evaluation and management (E/M) code. On the claim, report:

• 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 E/M
• L02.211 (Cutaneous abscess of abdominal wall) appended to 99214 to represent the patient’s abdominal abscess
• L02.212 (Cutaneous abscess of back [any part, except buttock]) appended to 99214 to represent the patient’s back abscess
• B95.61 (Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere) appended to 99214 to represent the patient’s abdominal abscess

Explanation: If there is an infectious agent causing the abscess, you need to include a code from B95 (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) through B97.- (Viral agents as the cause of diseases classified elsewhere) as a secondary diagnosis. This coding convention holds true when an underlying condition is causing most injuries in the ICD-10 range L00 (Staphylococcal scalded skin syndrome) through L08.- (Other local infections of skin and subcutaneous tissue).

Exception: If there isn’t an underlying infectious agent causing the abscess, don’t include a B95 through B97.- code. There is also an extensive list conditions that wouldn’t be cause to include a secondary code. These diagnoses appear at the beginning of the Tabular List for Chapter 12 of the ICD-10 manual, under the heading “Infections of the skin and subcutaneous tissue (L00-L08).”