ED Coding and Reimbursement Alert

When patients report to your ED for incision and drainage (I&D) of abscesses, you should be on the lookout for evidence of a complicated I&D, as this procedure pays an average of $72 more than a simple I&D.

But don't go coding a complicated I&D without proof that the ED physician performed one, or you will land in hot water with payers. Read on for this advice on reporting different types of I&Ds.

Your ED physician will often perform superficial (or simple) I&Ds, confirms Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich. You will typically use 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single).

"A superficial abscess will usually be right at the skin surface and will require a single incision to drain it," he says.

In a nutshell: A simple I&D "is an incision of an abscess, cyst, carbuncle, suppurative hidradenitis, cyst, furuncle, or paronychia that is situated just below the skin's surface or subcutaneously," explains Yvonne P. Mayer, CPC, senior coding analyst at Bill Dunbar and Associates LLC in Indianapolis.

One common example of a superficial I&D is a patient with folliculitis (704.09, 704.8), says one coding specialist at a Kentucky ED. "The area is red, the skin is swollen and painful to the touch and has a whitehead," she explains.

"While there is no size that indicates that an abscess is superficial, they are usually somewhat small and easy to incise; the pus inside is not coagulated, and it is removed easily with a small amount of irrigation," she explains.

Example: A patient reports to the ED with a bite mark on his right arm; he says "some kind of bug" bit him three days ago, and now the bite area is red, hot, and tender. A level-two E/M reveals a quarter-sized induration with a central pustule on the forearm, but no epitrochlear or axillary adenopathy. The ED physician diagnoses a 2-cm superficial abscess, makes a single incision with a No. 11 blade, and expresses pus from the wound; he then cleans and dresses the wound area. The patient is instructed to return to the ED for a wound check in one to two days.

This is an example of a simple I&D, confirms LaFleur. On the claim, report the following:

- 10060 for the I&D

- 99282 (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; and medical decision making of low complexity) for the E/M

- depending on the carrier, either modifier 57 (Decision for surgery) or modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and I&D were separate services

- 682.3 (Other cellulitis and abscess; upper arm and forearm) appended to 10060 and 99282 to represent the patient's injury.

ED physicians also perform complicated (or multiple) I&Ds, which you-ll code with 10061 (- complicated or multiple). The size of the wound will not indicate the complexity of an I&D, though the depth of the infection might. The patient may also require a local anesthetic injection to numb the area on a complicated I&D.

Also: Irrigation is more thorough, and usually takes several syringes to clear the wound, which is then packed with gauze.

In addition to packing, LaFleur says these are other characteristics of I&D procedures:

- the physician performs probing during the procedure

- the physician breaks up loculations within the abscess

- the abscess is very close to critical structures, such as arteries.

Check out this detailed clinical example from LaFleur. A female with type II diabetes with renal insufficiency who is taking oral hypoglycemics reports to the ED with an abscess on her left buttock; she also has a history of skin infections. She reports that she noticed a "sore spot" four days ago, and now the wound has grown to the size of a baseball and is quite tender.

During the course of a level-four E/M, the physician discovers a red, tender, 5-cm abscess on her left buttock. After the patient is prepped, the physician uses a No. 11 blade to cut about an inch into the patient's skin, draining a large amount of pus. The physician extends the incision to about three inches, and also breaks up several pus pockets with a clamp.

He then irrigates and packs the wound, performs a spot blood sugar check to make sure the procedure has not exacerbated the patient's diabetes, and directs the patient to follow up with her primary care physician.

The extra work the physician had to do to drain and pack the wound makes this a complicated I&D. On the claim, report the following:

- 10061 for the I&D

- 99284 (- a detailed history; a detailed examination; and medical decision making of moderate complexity) for the E/M

- depending on the carrier, either modifier 57 or modifier 25 appended to 99284 to show that the E/M and I&D were separate services

- 682.5 (- buttock) appended to 10061 and 99284 to represent the patient's abscess

- 250.40 (Diabetes with renal manifestations; type II or unspecified type, not stated as uncontrolled ) appended to 10061 and 99284 to represent the patient's diabetes.

It pays to know how to identify complicated or multiple I&Ds, as 10061 is worth almost twice as much as 10060.

The lowdown: 10060 is assigned 2.32 RVUs, which pays an average of $88 nationally; 10061 is assigned 4.18 total RVUs, which pays an average of $160 nationally. (To arrive at these figures, multiply the code RVUs by the current Medicare conversion rate of 38.0870.)

Bottom line: Get to know what separates simple from complicated I&Ds, and your practice's fiscal outlook will be brighter.