ED Coding and Reimbursement Alert

Plus: Find out how to differentiate between simple and complicated.

When patients present to the ED with infections or other issues requiring incision and drainage, you’ll need to be able to nail down the right I&D code. Consider the following tips when working to pinpoint a code so you keep your I&D reimbursement flowing.

Simple Skin Incision Marks Simple I&D

CPT^® indicates that for simple or single I&D procedures, you should report 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single), confirms Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

“Single or simple” in the 10060 descriptor “refers to wounds that primarily involve the ‘surface’ layers of the skin — epidermis, dermis, or subcutaneous tissues; whereas the deeper wounds involve the ‘deeper’ layers of the subcutaneous tissues,” she explains.

 According to CPT^® Assistant, “the choice of [I&D] code is at the physician’s discretion, based on the level of difficulty involved in the incision and drainage procedure.”

Best bet:  You should consult with the performing provider before deciding the level of repair to report for anI&D, if it isn’t spelled out in the notes. Here area few examples of lower-level, 10060-type I&Ds:

“For simple [I&D], I look for a single I&D and/or one that required a low level of difficulty,” says Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Oklahoma.

As simple or single I&Ds are characterized by “surface” repair, “the more complicated [I&D] abscesses are larger and may require probing to break up loculations and generally require packing,” according to Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, CPC, CPMA, CAC, CCS-P, CHC, chief executive officer of Edelberg+Associates in Baton Rouge, Louisiana. In most cases, both I&D types require antibiotic therapy, Edelberg confirms.

Example: A patient with a history of left shoulder surgeries presents with a painful axillary mass that is red, warm, and tender. The physician decides to perform an I&D. He numbs the area surrounding the abscess, covers the abscess with antiseptic, and drapes the site. He then opens and drains the abscess, probing to break up loculations and placing packing in the wound. The ED physician then covers the site with a bandage.

In this scenario, the provider performed a complex I&D. On the claim, you’d report 10061 for the I&D and the appropriate ED E/M code. CPT^® defines a simple I&D providing the example of a paronychia.

Remember to append 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) to the E/M code to show the payer that the E/M was separate and significantly identifiable from the procedure.

Do Deep Dive for Details on Complicated I&D

The difference between a 10060 service and 10061(… complicated or multiple) could depend on a number of factors, according to Pohlig.

“A ‘complicated’ I&D can often be substantiated when multiple incisions are required, or the abscess is complicated by:

• “the presence of an infection;
• “unusual length of time to perform I&D (15 minutes average for 10060 versus about 30 minutes for 10061); or
• “depth of I&D — requiring drain placement, packing, or subsequent wound closure).”
• Probing to break up loculations

Consider this example from Satkus: A patient presents with complaints of painful bump on his right leg, right buttock, and left groin. The area hurts when he touches it and the leg area was draining this morning. He put a warm compress on it last night, with no change in appearance.

The provider spots a large subcutaneous abscess on the patient’s right leg that is draining pus. The right buttock and left groin each have an area of bumps that are painful to the patient when touched, and both are draining pus.

The provider injects anesthesia and preps the patient’s right leg. She then incises the abscess with a #11 blade and drains large amounts of pus. The wound drains 3 cc of fluid and the abscess continues to drain, so the provider packs the area with gauze.

She then incises the right buttock and collects 1 cc of fluid, followed by incision and collection of 0.5ccof “foul-smelling liquid” from the left groin.

In this example, you’d report 10061 for the I&D with diagnosis codes L02.415 (Cutaneous abscess of right lower limb) and L73.2 (Hidradenitis suppurativa) appended to prove medical necessity.