Podiatry Coding & Billing Alert

Question: My 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 was red, swollen, and appears to be filled with pus, according to the documentation. 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. My podiatrist then irrigated the wound and put a dressing on it. My podiatrist diagnosed the patient with a cutaneous abscess of the right foot.

New York Subscriber

Answer: You should report 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) as the CPT^® code for this I&D procedure. You should report L02.611 (Cutaneous abscess of right foot) as the diagnosis code.

Explanation: In this case since your podiatrist performed a simple I&D for 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