Internal Medicine Coding Alert

Published on Wed Sep 26, 2007 PDF

Question: A new patient with a bump on his leg reports to the internist. He says the wound site is painful, red and sore. The internist documents the chief complaint (CC), reviews medical history with the patient and performs a review of systems (ROS) to check for any trauma to other systems. Then she performs a physical exam (PE), diagnoses an abscess and decides to perform an incision and drainage (I&D) on the patient to drain the wound, relieve pain and obtain cultures. The physician prescribes antibiotics, and she schedules the patient for a wound check in seven days. Should I report a procedure code and an E/M service for this encounter?

Virginia Subscriber

Answer: In this instance, the E/M meets the definition of a significant, separately identifiable service. The proper coding for your scenario includes a procedure code and an E/M-25.

On the claim, report the following:

• 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the I&D
• the appropriate-level E/M code based on the physician documentation. So if the notes indicate a separate level-two service, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making)
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to the E/M code to show that the E/M was separate from the I&D
• 682.6 (Other cellulitis and abscess; leg, except foot) linked to 10060 and the E/M code to prove medical necessity for both services.

For a more detailed explanation of proper modifier 25 use, see the paragraph below the modifier 25 descriptor in Appendix A of CPT 2007.