Internal Medicine Coding Alert

Complicated I&D code is twice as valuable as simple one

If you bill for a simple I&D when the internist performed a complicated one, you stand to lose almost $80 of deserved reimbursement.

To select the proper incision and drainage (I&D) code, you have to check the documentation to determine the I&D's complexity. Here's how to do that.

Before you select the proper I&D code, the documentation will need to support the complexity of the procedure. CPT indicates that for simple (or superficial) I&Ds, you should report 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia]; simple or single) for the service, says Elizabeth McDonald, CPC, coding specialist in the department of surgery at UPMC-Pittsburgh.

"Superficial refers to wounds that primarily involve the 'surface' layers of the skin --the epidermis, dermis, or subcutaneous tissues," says Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Example: An established patient presents with an upper arm mass that is red, warm, and tender. The internist performs a level-two E/M and decides to perform incision and drainage. He numbs the area surrounding the injury, covers the abscess with antiseptic and drapes the site.

Then the internist opens and drains the abscess. The site is covered with a bandage and left to heal on its own with wound care.

Pohlig says this will qualify as a simple I&D. On the claim, you should report the following codes:

• 10060 for the I&D.

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a 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) attached to 99212 to show that the I&D and E/M were separate services.

• 682.3 (Other cellulitis and abscess; upper arm and forearm) linked to 10060 and to 99212 to represent the abscess.

Patients may also report to the internist for complicated (or multiple) I&Ds. When this occurs, you should choose 10061 (... complicated or multiple) for the service, Pohlig says.

"A complicated I&D can often be substantiated when multiple incisions are required, or the abscess is complicated by the presence of an infection," Pohlig says. You might also be able to use 10061 if the I&D:

• takes an unusual length of time to complete;

• is especially deep; or

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

Bottom line: Coders who can differentiate between a simple and complicated I&D are worth their weight in gold, because code 10061 pays at a much higher rate than 10060. The 2007 relative value units (RVUs) for 10060 are 2.28; code 10061 sports 4.19 RVUs.

This translates to a Medicare reimbursement of $81.41 for 10060 and $158.79 for 10061.

Consider this guidance from the 2007 Coder's Desk Reference: "For complicated or multiple cysts in 10061, the physician may place a Penrose latex drain or gauze strip packing to allow continued drainage. Complicated cysts may require later surgical closure."

Example: The internist is performing an I&D on a patient with an infected forearm abscess. She incises to just above the cyst cavity and drains about 10 ml of foul-smelling pus. After the internist evacuates the pus, she excises the cyst wall from the surrounding tissue using electrocautery. Then she irrigates the wound with saline and places a drain in the cavity.

The internist then re-approximates the skin with two interrupted 3-0 nylon mattress sutures. Finally, she applies sterile gauze after cleaning and drying the skin.

Coding: This is an example of a complicated I&D, McDonald says. On the claim, you should report the following codes:

• 10061 for the I&D.

• 682.3 linked to 10061 to represent the patient's cyst.

Note: If the physician performed a significant, separately identifiable E/M service in addition to the I&D, then report the appropriate-level E/M code with modifier 25 attached