Primary Care Coding Alert

Question: Our physician assistant (PA) did an incision and drainage (I&D) (10060) for abscess of finger (681.00). Medicare has denied the claim, indicating the diagnosis is inconsistent with the procedure. Should I instead use 686.9 or 915.6?

New York Subscriber

Answer: The problem is that a more anatomically specific CPT code exists for the scenario you describe. You should bill simple I&D of an abscess of the finger with 26010 (Drainage of finger abscess; simple). Code 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) represents incision and drainage of an abscess involving the skin, including subcutaneous or accessory structures.

CPT, however, also contains numerous codes that are specific to the I&D of an abscess in various anatomical sites. "Therefore, it would be appropriate to bill these more specific incision and drainage codes," according to HealthNow's (Part B carrier for upstate New York) I&D local coverage determination. For example, "an abscess of the finger should be billed with CPT codes 26010-26011 (Drainage of finger abscess)."

In 26010, the physician lances an abscess located in the cutaneous tissue of a finger. Drainage of an abscess (681.00, Cellulitis and abscess of finger and toe; finger; unspecified) shows medical necessity for 26010.

You would use the other diagnoses you mention in the following situations. If the infection is of unknown origin or cannot be classified into one of these categories, you might consider 686.9 (Unspecified local infection of skin and subcutaneous tissue). For foreign body removal, such as of a splinter, you would use 915.6 (Superficial injury of finger[s]; superficial foreign body [splinter] without major open wound and without mention of infection).

Expect to use 10060 when no more specific abcess I&D code exists other than the skin code. For instance, you could use 10060 with 682.3 (Other cellulitis and abscess; upper arm and forearm) for I&D of an upper arm mass that is red, warm, and tender.