Orthopedic Coding Alert

Question: Our provider recently drained an abscess on one of our patients. What documentation is necessary to support the claim?

South Carolina Subscriber

Answer: In order to code and bill for the treatment, the first thing you will need to document is the procedure your provider used on the patient. If the provider used a needle to drain the pus out of a simple abscess, you would code 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst); if the abscess is more complex and required undermining the skin and subcutaneous skin, and an extensive laying open of the cavity, you would use 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 the amount of work your provider performed during the procedure.

If this was a deep abscess, you would report the appropriate repair code form the musculoskeletal section — for example, 25028 (Incision and drainage, forearm and/or wrist; deep abscess or hematoma).

For any of these procedures, you will need to provide a procedure note (similar to an actual op note) that details how the procedure is being performed, the results of the procedure, and how the patient tolerated the procedure. You will also need to provide a description of the patient’s abscess, including details such as where the abscess was located, its size and appearance, and any other signs or symptoms related to it. If, in this description, you provider documents that the patient had anything other than an abscess — for example, if the patient had a blister or there was no documentation of pus collection, pain, infection, or inflammation — you cannot use any of these codes.

Then, if your provider did perform an incision and drainage (I&D) procedure, you should also document the anesthesia used on the patient; any antibiotic medication, either oral or topical, that you provider prescribed; and results of a culture and sensitivity test on the pus that your provider removed.