Orthopedic Coding Alert

Question: Notes indicate that the provider performed a level-four evaluation and management (E/M) service for a new patient, and then performed, according to the notes: “I&D R hip joint deep.” How should I code this encounter?

Oregon Subscriber

Answer: You’ll need to be sure that the provider performed a “deep” I&D by CPT^® standards before choosing a code for the surgery. During a “deep” hip I&D, the incision could extend to the fascia or even muscle. The provider will likely then cut into the lesion and use a syringe or catheter to drain the wound.

If this sounds like the type of service your surgeon provided, then report 26990 (Incision and drainage, pelvis or hip joint area; deep abscess or hematoma) for the I&D. Also, report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity …) with modifier 57 (Decision for surgery) appended to show that the surgeon opted for I&D after a significant and separately identifiable E/M service.

Do this for “shallower” I&D: If you cannot find enough evidence to support a 26990 claim, you’ll have to report either 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) or 10061 (…  complicated or multiple), depending on encounter specifics.

Also, if you do choose 10060 or 10061, you’ll have to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99204 rather than 57; remember, 57 is for E/Ms preceding “major” procedures (global period of 90 days) and 25 is for E/Ms preceding “minor” procedures (global period of 0 or 10 days).