Identify the I&D Procedure Code for a Right Arm Abscess
Question: A patient presented to their primary care physician (PCP) on a Monday with complaints of inflammation, pain, and stiffness in their right arm. They thought they were bitten by an insect over the weekend but weren’t sure. The physician examined the patient and noted the area in question appeared red and there was some swelling. The PCP drew a line around the red area and said to monitor the condition. Two days later, the patient returned. The redness had spread beyond the line, the patient was experiencing sharp pain in the arm, and the wound had developed into an abscess. The PCP diagnosed the patient with a subcutaneous abscess, performed an incision & drainage (I&D) procedure, and packed the wound to allow additional drainage over the following 24 hours. What I&D code should I assign for this procedure? South Carolina Subscriber Answer: Use 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple) to report the I&D procedure. The physician incised the abscess to remove the contents from the wound but then added a drain to ensure any remaining material would exit the wound. According to the American College of Emergency Physicians, a complicated I&D “may require multiple incisions, drain placement, wound packing, or probing to break up loculations within the abscess.” The documentation should also include as many details as needed to justify the procedure. The Centers for Medicare & Medicaid Services (CMS) requires providers to document: Mike Shaughnessy, BA, CPC, Production Editor, AAPC
