Orthopedic Coding Alert

Question: A patient reported to the provider for incision and drainage (I&D) of a foot abscess. I thought the code choice would be relatively easy, but there are several options for foot I&D. Could you tell me a little more about the coding options for these services?

New York  Subscriber

Answer: If the I&D is for a simple or single abscess, you’ll report 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) for the service. When the abscess is complicated, or when multiple abscesses are involves, you might report 10061 (… complicated or multiple).

Differences: According to Codify: “A simple incision and drainage usually involves a single incision of an abscess situated just below the skin’s surface. A complicated incision and drainage can involve multiple incisions, drain placements, extensive packing, and a more complicated wound closure.”

When the I&Ds go below the surface, you coding will change accordingly. The codes get more specific as to anatomy, as well as to the provider’s actions. If 10060-10061 do not adequately describe your provider’s services, you might consider the following codes:

• 28001 (Incision and drainage, bursa, foot). In this procedure, the provider drains fluid from an infected bursa of the foot. “A bursa is a fluid filled sac that lies between the muscle, tendon, and bones,” reports Codify.
• 28002 (Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space). This I&D is similar to 28001, but in 28002 the provider drains infected material that may involve the covering of the tendon.
• 28003 (… multiple areas).