Internal Medicine Coding Alert

Question: A new patient presents to the internist complaining of a new painful mass on his left shoulder blade. During the course of a level-two E/M, the internist diagnoses a single carbuncle, which he then incises and drains. How should I code this scenario?

Maryland Subscriber

Answer: You should code separately for the E/M and I&D, but include the same diagnosis code for each CPT code. 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 of the carbuncle

• 680.3 (Carbuncle and furuncle; upper arm and forearm) linked to 10060 to represent the carbuncle

• 99202 (Office or other outpatient visit for the E/M of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the E/M

• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99202 to show that the E/M and I&D were separate services

• 680.3 linked to 99202 to represent the carbuncle.