Orthopedic Coding Alert

Question: What is the difference between an incision and drainage (I&D) and a foreign body removal (FBR)? I would have thought that an abscess was a foreign body, but it seems to have its own CPT^® code.

Montana Subscriber

Answer: Semantics aside, an I&D is not an FBR for coding purposes. We’ll take a quick look at how to code both services:

I&D: If the notes indicate that the provider cut into (incised) an abscess, cyst, carbuncle, etc., in order to let fluid or other material out of the wound (drainage), it’s an I&D. You’d report 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) for these I&Ds, depending on the complexity of the service.

There are also some codes for specific types of I&Ds, which you should use in lieu of 10060 and 10061 in certain situations. These are some of the other I&D codes that you might choose for your provider’s service, depending on encounter notes:

• 10080 — Incision and drainage of pilonidal cyst; simple
• 10081 — … complicated
• 10140 — Incision and drainage of hematoma, seroma or fluid collection
• 10160 — Puncture aspiration of abscess, hematoma, bulla, or cyst 
• 10180 — Incision and drainage, complex, postoperative wound infection.

FBR: When the provider makes an incision and removes an object foreign to the human body — such as a splinter, a shard of glass, etc. — then you would report one of the following FBR codes, depending on encounter specifics:

• 10120 — Incision and removal of foreign body, subcutaneous tissues; simple
• 10121 — … complicated.

FBR incision decision: You need proof that the provider performed an incision in order to report an FBR code. If the notes do not indicate an incision, you’ll have to report the appropriate evaluation and management (E/M) code for the service.

So if the notes indicate that the provider removed a wooden splinter from an established patient’s hand using only tweezers in an office setting, you’d report the appropriate code from 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …), depending on the level of service.

Remember: This is not an exhaustive list of I&D/FBR codes; the above advice is just a primer on the basics (and the basic codes) of I&D/FBR coding. There are numerous other codes in the musculoskeletal section of CPT^® that you should use for more specific I&Ds and FBRs. Some examples are 20520 (Removal of foreign body in muscle or tendon sheath; simple), 25248 (Exploration with removal of deep foreign body, forearm or wrist), 27301 (Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region), 27372 (Removal of foreign body, deep, thigh region or knee area), and 28190 (Removal of foreign body, foot; subcutaneous).