ED Coding and Reimbursement Alert

Question: Encounter notes indicate that the ED physician performed an incision and drainage (I&D) that involved extensive packing and drain placement. Is this a complicated I&D?

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Answer: Yes. Generally, a complicated I&D may include wound packing, drain insertion, and/or probing and deloculation. The ED provider determines the appropriate technique needed treat the I&D and should document them in the ED chart.

The procedure note could include details of the procedure, including the incision or puncture, the amount and quality of drainage; probing and deloculation (when performed); and whether the wound was packed, a drain inserted, a vessel loop placed or left open. Per CPT^®, multiple skin or subcutaneous I&Ds during the same encounter are also coded as complicated rather than multiple simple I&D procedures. Extensive packing or drain placement are typically indications of a more complex abscess reported with 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple).

Keep in mind, CPT^® provides examples of a simple abscess (CPT^® code 10060 [… simple or single]) and describes a paronychia.