Podiatry Coding & Billing Alert

Question: The podiatrist examined a 23-year-old male patient who complained of severe pain and tenderness in the area of the heel of his right leg. The patient said he had an injury three days prior when he hit his foot against a sharp edge of a wooden stool. Upon examination, the podiatrist noted that the area was red, swollen, and appeared to be filled with pus. The podiatrist made an incision using a No.11 scalpel and drained the pus from the wound. Your podiatrist then irrigated the wound and placed a dressing. Should we report 10060 or 10061 for this service?

North Carolina Subscriber

Answer: Since your physician drained a simple, superficial abscess, 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 this I&D procedure.

Simple I&D: You would report 10060 for a simple I&D procedure and for 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.

Caution: 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. 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 the 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. Your podiatrist might also use packing when performing an I&D of a complicated abscess. Alternatively, you will also use 10061 when you are reporting incision and drainage of multiple, simple abscesses.