ED Coding and Reimbursement Alert

If you can differentiate between a simple and complicated I&D, you-re worth your weight in gold. Code 10061 brings in more dollars than 10060.

There are different codes for simple and complicated incision and drainage (I&D), as well different code sets for pilonidal cyst treatment. When a patient requires repair in the ED, you have to check the documentation to determine the complexity of the I&D. Master the ins and outs with these tips.

Before selecting the proper I&D code, you will need to decide the complexity of the procedure. CPT indicates that for simple (or superficial) I&Ds, you should report 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia]; simple or single).

-Simple I&Ds involve abscesses of the epidermis, dermis or subcutaneous layers,- says Jeffery F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga.

Example: The ED physician treats a patient who has been scratching at an insect bite on his lower arm and now has pus draining from it. The abscess is in the dermis. The physician cleans the skin around the wound and makes a small scalpel incision. The physician then drains the pus, and cleans and dresses the wound site.

Linzer says this will qualify as a simple I&D. You should report the following codes:

• 10060 for the I&D.
• 682.3 (Other cellulitis and abscess; upper arm and forearm) linked to 10060 to represent the abscess.
• 913.5 (Superficial injury of elbow, forearm and wrist; insect bite, nonvenomous, infected) linked to 10060 to represent the insect bite.

Note: If the physician performed a significant, separately identifiable E/M service in addition to the I&D, report the appropriate-level E/M code with modifier 25 attached, Linzer says.

Suppose notes indicate a level-three E/M in this example. On the claim, you would include 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem- focused examination; medical decision-making of moderate complexity) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached.

Patients will also report to the ED for complicated (or multiple) I&Ds. When this occurs, you should choose 10061 (... complicated or multiple) for the service, says Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

Bottom line: Coders who can differentiate between a simple and complicated I&D are of great value, because 10061 pays at a much higher rate than 10060.

The 2007 relative value units (RVUs) for 10060 are 2.28; code 10061 sports 4.19 RVUs. This translates to a Medicare reimbursement of $86.41 for 10060 and $158.79 for 10061.

And you-ll get plenty of chances to choose between simple and complex I&Ds.

According to Contreras, -Complex I&Ds are very common in the ED setting. You should report the 10061 code when the physician treats more than one small

superficial (simple) abscess, or a single larger or more complicated abscess.-

Clues to complicated I&D: If the physician is treating a single large (or complicated) abscess, he will typically use probing to break up loculations; he might also use packing, Contreras says.

Example: A patient presents with pain and swelling localized to the arm that started two days ago. He has mild discomfort with movement and denies any injury.

The exam reveals signs of infection in the upper extremity and mild erythema localized to the right arm in a 2-cm area. The physician cleans the skin with Betadine, then cuts the abscess open and drains a moderate amount of pus. After obtaining samples for cultures, the physician irrigates the cavity, probes to break up loculations and packs it with gauze.

Coding: This is an example of a complicated I&D. On the claim, report the following codes:

• 10061 for the I&D.
•  682.3 (Other cellulitis and abscess; upper arm and forearm) linked to 10061 to represent the patient's injury.

Note: If the physician performed a significant, separately identifiable E/M service in addition to the I&D, report the appropriate-level E/M code with modifier 25 attached, Linzer says.

Choose Different Codes for Pilonidal I&Ds

While you will use 10060 and 10061 for most of your ED I&Ds, the physician may also have to drain abscesses in recognized, specific, anatomically defined areas -- such as pilonidal cysts. When this occurs, you should report 10080 (Incision and drainage of pilonidal cyst; simple) or 10081 (... complicated) for the service, depending on the complexity of the I&D.

Definition: -A pilonidal cyst is caused by trapped epithelial tissue located in the sacro-coccygeal region above the buttocks and is usually associated with ingrown hair,- Contreras says. Pilonidal cysts can produce fluid or exudate into the cystic lining, and may or may not contain an abscess.

Consider this example from Linzer: A child has been having pain and discomfort when she sits down. Her mother noticed some yellow discharge in her underwear, and brings the child to the ED.

The physician discovers that a pilonidal cyst is causing the problem. The physician cleans and preps the area, then makes a small incision with a scalpel, expressing a small amount of pus. He cleans and dresses the drainage site and sends the patient home. On the claim for this example, report the following codes:

• 10080 for the I&D.
• 685.0 (Pilonidal cyst; with abscess) linked to 10080 to represent the pilonidal cyst.

Note: If the physician performed a significant, separately identifiable E/M service in addition to the I&D, report the appropriate-level E/M code with modifier 25 attached, Linzer says.