Radiology Coding Alert

Question: After a CT maxillofacial scan without contrast, our radiologist performed and incision and drainage of a masseter muscle abscess.

How do I report the procedures?

Arkansas Subscriber

Answer: You’ll start by assigning 70486 (Computed tomography, maxillofacial area; without contrast material) to report the computed tomography (CT) scan of the patient’s maxillofacial area. Of the three CT maxillofacial scan code choices, 70486 is the only one that is performed without contrast material, which makes it the correct option.

Next, you’ll want to turn to the CPT® Index to find the incision and drainage (I&D) code choices. Follow Incision and Drainage > Abscess > Skin to find the following codes:

• 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single)
• 10061 (… complicated or multiple)

The difference between 10060 and 10061 depends on the number of incisions and the extent of the procedure. You’ll assign 10060 if the provider performs a simple I&D, whereas you’ll assign 10061 if the provider performs a complicated I&D with multiple incisions, drain placements, or extensive packing.

One of the facial muscles, the masseter muscle is a superficial muscle that assists in the chewing process. Abscesses can form in the muscle and a provider may be asked to perform an I&D procedure to drain fluids from the abscess. The drainage helps the healing process.

Masseter muscle abscesses tend to bulge out toward the subcutaneous tissue and skin. Even though the abscess is located in the muscle, the I&D procedure won’t reach that deep, which satisfies the requirements for 10060 or 10061.