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 [...]