Primary Care Coding Alert

Question: Our physician completed a detailed history and exam on an established patient who complained of testicular pain. The physician performed an I&D on the scrotum's abscess. What procedure and diagnosis codes should I report?


Massachusetts Subscriber

Answer: When your physician performs a procedure during a patient's office visit, you can only code for the procedure because the office visit charges are included in the procedure.

Report 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the abscess procedure with diagnosis 608.4 (Other inflammatory disorders of male genital organs). Some coders recommend diagnosis 608.9 (Unspecified disorder of male genital organs), so talk with your physician about the better choice.