Outpatient Facility Coding Alert

Question: A new patient comes to the office with complaints of acute pain and tenderness in the heel of his left foot. The patient says he suffered the injury three days ago when he stepped on a nail. After a detailed history and examination, the dermatologist determines that the area is inflamed, tender, and infected with pus. The dermatologist provides an evaluation and management (E/M) service and notes indicate low-complexity medical decision making to pinpoint the injury. Using a No.11 scalpel, she makes an incision and drains the pus from the wound. The dermatologist then irrigates and dresses the wound. How should I report this encounter?

Maine Subscriber

Answer: On this claim, you should report an incision and drainage (I&D) code plus a separate evaluation and management (E/M) code — if the notes back up the extra E/M.

On the claim, report 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the I&D. Then, if you can prove that the physician provided a significant, separately identifiable E/M pre-I&D, report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity) for the E/M 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.

Turn to CPT^® 10060 when your clinician performs an I&D of an abscess that is located in the superficial layers of the skin (dermis, epidermis, or subcutaneous layers) and does not have any deep extensions. When draining a simple abscess, your clinician will make a simple incision that will help drain out the pus.

On the other hand, you will report 10061 (… complicated or multiple) when the abscess is located deeper. You also might be able to report 10061 when:

• The dermatologist spends more time than typical to drain the abscess;
• The abscess contains loculations that the dermatologist needs to be probe extensively to help drain the abscess;
• The dermatologist is performing I&D of more than one abscess; or 
• The notes indicate that the dermatologist used packing, placed a drain, or performed a layered closure at the incision site.

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