General Surgery Coding Alert

Question: Our surgeon evaluated a 56-year-old male patient with complaints of pain and swelling in the area of the second toe on the left foot. The surgeon documented that the pain started about two days ago, and that 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 appeared to be filled with pus. He numbed the area with a local anesthetic, and 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: Because there is not a site-specific abscess drainage code for an abscess of the toe, you might use one of the following codes:

• 10060 — Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
• 10061 — …complicated or multiple
• 20005 — Incision and drainage of soft tissue abscess, subfascial (i.e., involves the soft tissue below the deep fascia).

Given that your surgeon probed the abscess to break up loculations and packed gauze, the incision and drainage (I&D) does not appear to be simple, so 10061 looks more appropriate of the skin code choices. However, it appears that the abscess may be entirely subcutaneous, based on the fact that the patient didn’t know why the toe was hurting. If the documentation makes it clear that the abscess is deep, the skin codes are not appropriate, and you should code 20005 for the I&D.

Because your surgeon also performed an evaluation relative to the patient’s diabetes that is separate from the preliminary investigation typical before performing an I&D, you should also report an E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) in addition to 20005. Append modifier 25 (Significant, separately identifiable evaluation and management 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 are separately identifiable.