Pediatric Coding Alert

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

Codify Subscriber

Answer: In order to code and bill for the treatment, the first thing you will need to document is the procedure your pediatrician 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 pediatrician performed during the procedure.

For either of these procedures, you will need to provide a procedure note (similar to an actual op-note) that details how your provider performed the procedure, 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, your 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 pediatrician 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.