General Surgery Coding Alert

Question: Our surgeon reviewed a 29-year-old female patient with complaints of acute pain and tenderness in the area of the wrist. Upon examination, he diagnosed the patient with a deep abscess not involving the bursa, and performed an incision to drain the abscess. The op report documents performing extensive probing to break down loculations, and then cleaning and irrigating the wound along with placing sutures and dressings. What code should we use to report this procedure?

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Answer: In this case scenario, the best choice is 25028 (Incision and drainage, forearm and/or wrist; deep abscess or hematoma) for the incision and drainage procedure described by the documentation.

Some coders are surprised to learn that CPT^® codes 10060 and 10061 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia] …) are not the only codes available to report an incision and drainage of an abscess. CPT^® also has some site-specific codes that you should report when your clinician performs an I&D of an abscess that is located at one of these specified sites.

In fact, CPT^® guidelines instruct you to report these site specific codes (when available) instead of reporting 10060 or 10061.

There are two site specific codes that you can choose from when your clinician performs an I&D in the wrist: 25028 and 25031 (…bursa). Because in the scenario described, your clinician performed an I&D of an abscess deep in the wrist and not an I&D of an infection of the bursa, you should report 25028 and not 25031.