Podiatry Coding & Billing Alert

Question: Our podiatrist recently performed incision and drainage of a right foot abscess. The notes mentioned “the incision penetrated the fascia.” Should I continue with 10060 or 10061 for the procedure? How do I differentiate whether the procedure was simple or complicated? Please do let me know as different people are giving different opinions.

New Jersey Subscriber

Answer: In this case scenario, you should report neither 10060 nor 10061 for the procedure that your physician performed. The term “fascia” gives a totally new meaning to the codes and you are better off using site specific codes for you to report drainage of an abscess of the foot. You can report from one of the following two codes depending upon the exact location of the drainage:

• 28001 (Incision and drainage, bursa, foot)
• 28002 (Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space).

You will need to choose 28001 when your physician is performing drainage of a abscess involving the bursa. You will need to choose 28002 when your clinician is draining a more complicated and serious infection. When performing incision and drainage (I&D) on superficial or deep abscesses, documentation that carefully notes the location of the abscess is required. This tells the carriers that the procedure is medically necessary.

Note: Check documentation to see the location and size of the abscess to determine if your podiatrist is draining a simple or complicated abscess. If you are not able to garner from the documentation whether your clinician drained a simple or a complicated abscess, check with your physician, so you can choose the right code for the procedure performed. Ultimately, it is the physician’s judgment whether the procedure was “simple” or “complicated.”