Orthopedic Coding Alert

Question: After performing a level three new patient office evaluation and management (E/M) service , the physician performs incision and drainage (I&D) of an abscess on the patient’s left elbow. Notes indicate ‘deep’ I&D, but I’m not sure if it would qualify for a deep I&D code. Could you tell me how I can discern whether this was a standard or deep I&D?

Missouri Subscriber

Answer: You are right to be unsure; just because the notes read “deep” does not necessarily mean that a deep I&D occurred for coding purposes.

Typically, a deep I&D will surpass the epidermis into the dermis — and could go all the way to the subcutaneous fat surrounding bone or the bone itself (in this case it would be the humerus).

When this occurs, you’ll choose 23930 (Incision and drainage, upper arm or elbow area; deep abscess or hematoma) for the I&D.

So, if you can prove that the surgeon performed I&D on a deep abscess, report 23930 with modifier LT (Left side) appended to indicate laterality, if the payer requires it. Then, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) with 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) appended to show that the E/M was a significant and separate service from the I&D.

If, however, you cannot show that the I&D was truly deep, opt for a code from the 10040 (Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)) through 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst) code set. Your most likely options for shoulder I&D you describe are 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).

Complicated vs. simple: If you decide the shoulder abscess isn’t deep enough for 23930, you’re going to have to decide if it was simple or complicated in order to choose between 10060 and 10061. For coding purposes, a complicated I&D can involve multiple incisions, drain placements, extensive packing, and a more complicated wound closure.

Best bet: If you were thinking of reporting 23930 and the I&D wasn’t deep enough, it may qualify for 10061 — but be sure to check with your provider before coding. Whether you choose 10060 or 10061, be sure to append modifier LT to the code if the payer requires it.

Also, don’t forget to report 99213 with modifier 25 appended.