General Surgery Coding Alert

Question: Our surgeon performs an incision and drainage on Jan. 2, and the patient returns to the office on Jan. 7 for a follow-up appointment. Noting redness and "weeping" at the site, the surgeon reopens the abscess with an 18 gauge needle and applies pressure to encourage drainage. How should we bill the visit?

Texas Subscriber

Answer: You should bill the follow-up appointment by reporting the incision and drainage procedure rather than an E/M code. You should list 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single).

Presumably you billed the initial procedure as 10060 as well.

Watch modifier: Because 10060 has a 10-day global period and the follow-up visit falls within that time frame, you’ll need to use a modifier to allow you to bill the second procedure.

The office visit was a scheduled follow-up, and the second procedure was related to the initial procedure, so you should use modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period).

Caution: This procedure might not be billable at all, depending on the payer and how the physician documents the work. If the Jan. 7 visit is for a complication, you can’t bill the service to Medicare since it doesn’t require a return to the OR. If the service is instead progression of the condition, it is billable with a modifier such as 58.

If the condition is a complication and requires a trip to the OR, modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) is appropriate.