Internal Medicine Coding Alert

Question: Would you explain the difference between a simple and complicated incision and drainage (I&D)? What are some clues that the internist might have performed a complicated I&D?

Oklahoma Subscriber

Answer: Simple I&D occurs when the internist treats wounds that involve the surface layers of the skin (epidermis, dermis). You'll code these encounters with 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia]; simple or single).

Example: A patient presents to the internist with a pus-filled lump on her left thigh. After prepping the patient for the procedure, the internist cuts through the epidermis and dermis and drains the wound. For this encounter, you'd report 10060.

When the internist performs complicated I&D, choose 10061 (... complicated or multiple) instead of 10060. You might consider reporting 10061 rather than 10060 if the I&D:

• occurs at multiple sites

• requires multiple incisions

• takes an unusual length of time to complete

• is especially deep

• requires drain placement, more extensive packing, or subsequent wound closure.

Example: A patient with a forearm abscess reports to the internist. After making three incisions to the affected area, the internist drains the cyst. He then irrigates the area with saline and places a drain. For this encounter, you'd report 10061.

Note: Check your carrier's policy to see what types of documentation it wants on your I&D claims. Without strong medical record documentation, the carrier may deny the claim because you did not accurately reflect medical necessity or the work done. For more information on documentation for I&D claims, see the CMS site http://www.cms.hhs.gov/MCD/viewarticle.asp?article_id=19601&article_version=10&show=all.