Medicare Compliance & Reimbursement

Question: Our physician performed a level-four E/M service in the emergency department for a patient and diagnosed a peritonsillar abscess. Notes indicate that the physician aspirated the abscess to confirm the presence of pus, and then incised and drained it. Is this a 10060 incision and drainage (I&D)?

Answer: These types of abscesses have their own I&D codes. For this encounter you would report the following codes:

• 42700 (Incision and drainage abscess; peritonsillar) for the I&D

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M

• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M and aspiration were separate services

• 475 (Peritonsillar abscess) appended to 42700 and 99284 to represent the patient's abscess.

As you can see from the 42700 descriptor, it is a more accurate code choice than 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for this particular I&D.