Podiatry Coding & Billing Alert

Remember: To report 10060, the abscess must be simple or single.

When your podiatrist performs an incision and drainage (I&D) of an abscess, you must pay close the attention to the medical documentation. For example, you have to identify whether the I&D was simple or complicated. You should also know how many abscesses the podiatrist treated.

Read on to learn more about how to submit clean abscess I&D claims in your podiatry practice.

Pinpoint Correct Simple I&D Code

You should report 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) for a simple I&D procedure and the incision and drainage procedure of an individual lesion. A simple I&D involves drainage of an abscess that is present in the superficial layers of the skin. This will involve usually the dermis, epidermis, or the subcutaneous layers of the skin and will not have any deeper or extensive involvement. When your podiatrist drains a simple abscess, he will usually make a simple incision that will drain the pus present in the abscess.

Don’t miss: The code descriptor for 10060 describes what qualifies as an abscess, which includes the following:

• Carbuncle
• Suppurative hidradenitis
• Cutaneous or subcutaneous abscess
• Cyst
• Furuncle
• Paronychia

Note: To report 10060, the abscess must be simple or single.

Coding example: The podiatrist used a No. 11 scalpel to make a simple incision over the target area of a simple, cutaneous abscess located in the area of the heel of the patient’s right leg. The area is red, swollen, and appears to be filled with pus. The podiatrist opened the abscess, which was at the dermis level of the skin, and removed the inflamed fatty and dead tissue within the cavity and completely drained the pus. The podiatrist then irrigated the wound and put a dressing on it. The podiatrist diagnosed the patient with a cutaneous abscess of the right foot.

Coding solution: Since your physician drained a simple, superficial abscess, you should report 10060 for this I&D procedure. You should report L02.611 (Cutaneous abscess of right foot) as the diagnosis code.

Rely on 10061 for Complicated or Multiple I&D

On the other hand, you should report 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple) when your podiatrist drains a complicated abscess or multiple abscesses.

Complicated I&D explained: The size of the abscess might not give an indication about the complexity or complication, but depth of infection might help. Your podiatrist might use a local anesthetic to numb the area prior to performing a complicated I&D. Also, a complicated I&D will involve treating an abscess that contains many loculations, which will need extensive probing by your clinician to drain completely. Also, if there is need to place a drain or pack the area for continuous drainage, then you should report 10061, says Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan.

The difference between a 10060 service and 10061(… complicated or multiple) could depend on a number of factors, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania:

“A complicated I&D can often be substantiated when multiple incisions are required or the abscess is complicated by the following,” Pohlig explains:

• The presence of an infection;
• Unusual length of time to perform I&D (15 minutes average for 10060 versus about 30 minutes for 10061); or
• Depth of I&D — requiring drain placement, packing, or subsequent wound closure)
• Probing to break up loculations

Rely on 28001, 28002, 28003 if Podiatrist Goes Beyond the Fascia

If the podiatrist’s incision for the abscess penetrates the patient’s fascia, which is beyond the cutaneous layer, then you would not report 10060 or 10061. Instead, when the podiatrist performs an I&D of a non-integumentary abscess in the foot, you should turn to 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.
• 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)

Coding example: The podiatrist performed an I&D of a below the fascia abscess of the foot. According to his documentation, the podiatrist went beyond the cutaneous layer to the fascia. The podiatrist also drained infected material that involved the covering of the tendon. The podiatrist only drained one bursal space. You should report 28002 for this procedure.