Ob-Gyn Coding Alert

Question: My ob-gyn performed a right perineal abscess incision and drainage as well as debridement. The findings were -necrotic tissue with areas of erythema and induration in the right perineum.- Should I use 11004 or 56405?

California Subscriber

Answer: You-ll want to get this right because there is a huge difference in relative value units (RVUs) for these two procedures. Code 11004 (Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum) has 15.20 RVUs and can only take place in a facility setting, but 56405 (Incision and drainage of vulva or perineal abscess) has 2.92 RVUs in the office setting and 2.77 RVUs in a facility setting.

Ask yourself, was the debridement extensive and where did your ob-gyn perform the procedure? CPT added 11004 in 2005 to identify extensive debride-ment procedures on high-risk patients. Not only would the physician perform this procedure in an operating room, but also the documentation must describe extensive debridement of the necrotic skin, subcutaneous tissue, fat and muscle down to healthy tissue. The procedure includes placing drains and packing the open wound. If your ob-gyn performed this procedure, you should use 11004. 

Keep in mind: You may need a diagnosis of necrotizing fasciitis (728.86) to support medical necessity for 11004 as well. Make certain your ob-gyn's documentation supports using 726.86.

If your ob-gyn performed this procedure in the office, use 56405. You may want to add modifier 22 (Unusual procedural services) for the debridement if your ob-gyn's documentation shows that it was extensive.