EM Coding Alert

Question: Our physician reviewed a 56-year-old male patient with complaints of pain and swelling in the area of the second toe on the left leg. He documented that the pain started about two days ago, and the patient didn’t remember any injury to the area. Upon examination, the physician noted an approximately 2 cm swelling in the area of the toe that appears to be filled with pus. He numbed the area with a local anesthetic, then performed a single incision using a No. 11 scalpel blade. He then drained the pus and then probed into the area to break up some loculations that drain out more pus. He then irrigated the area and packed the wound with gauze. The patient has diabetes, so the physician investigated further to check the patient’s sugar levels to see if there is going to be any additional or adverse problems due to his diabetes. How should I code this encounter?

Pennsylvania Subscriber

Answer: Since your physician probed the abscess to break up loculations and packed gauze, the incision and drainage (I&D) does not appear to be simple, and you may report the I&D with 10061 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple).

Since your clinician performed an evaluation that is separate from the preliminary investigation that your clinician typically performs prior to the I&D, you will report this evaluation with an E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) in addition to 10061. Append modifier 25 (Significant, separately identifiable evaluation and management [E/M] service by the same physician or other qualified health care professional on the same day of the procedure or other service) to show that the E/M and I&D were separately identifiable.

You report the diagnosis with 681.10 (Unspecified cellulitis and abscess of toe) if you are using ICD-9 codes or report L03.039 (Cellulitis of unspecified toe) or L03.049 (Acute lymphangitis of unspecified toe) when using ICD-10 codes. You will also need to include the underlying cause of diabetes with your claim — 250.xx for ICD-9 and E19.---- for ICD-10.