Primary Care Coding Alert

Question: A 38-year-old new patient presents to the FP complaining of pain and swelling in his left thigh. A qualified nonphysician practitioner (NPP) obtains a detailed history and, due to the nature of the chief complaint, the physician performs an expanded problem focused exam, which reveals an abscess resembling cellulitis on the right thigh. The FP opens the abscess with a scalpel and drains the contents. She then gently irrigates the area with saline, loosely dresses and covers the wound, and discharges the patient with prescriptions for antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) for pain, with instructions to follow up within two weeks for dressing change. Is this a simple or complicated incision and drainage (I&D)?

Connecticut Subscriber

Answer: You should classify this service as a simple I&D. On the claim, report the following:

• 10060 (Incision and drainage of abscess [e.g.,carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia]; simple or single) for the I&D,

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...) for the E/M,

• modifier 25 (Significant, separately identifiableevaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the I&D and E/M were separate services, and

• 682.6 (Other cellulitis and abscess; leg, except foot) appended to 10060 and 99202 to represent thepatient's abscess.

Coding 10061 is ... complicated: If your FP performs multiple simple I&Ds, then you can report 10061 (... complicated or multiple). True complicated I&Ds are rarely performed by FPs. Some aspects of a complicated I&D include:

• insertion of drainage device, catheter, wick, packing,

• treatment of an excessively large cyst, and

• performance of an excessively complex drainage.

Also, the I&D could be complicated if notes indicate that the physician had to break up loculations within the abscess. The 10061 is a rarity for FPs, however, so check with the physician before using it.