Radiology Coding Alert

Question: Our radiologist performed an incision and drainage (I&D) of a masseter muscle abscess following a computed tomography (CT) maxillofacial scan. What’s the coding for the I&D?

Alabama Subscriber

Answer: The masseter muscle is a superficial facial muscle that’s primarily involved in the chewing of foods. While abscess formation may be uncommon, a provider may be called upon to perform an I&D service to drain fluids from the abscess in order to facilitate the healing process.

Since the provider performed the I&D via an external approach (through the skin and subcutaneous tissue), you will proceed by following the CPT^® index route Incision and Drainage ? Abscess ? Skin, which yields codes 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) and 10061 (…complicated or multiple).

Given the superficiality of the masseter muscle, abscesses tend to protrude outward via the subcutaneous tissue and skin. While the abscess itself originates from the muscular tissue, the actual I&D doesn’t reach to that anatomic level, and therefore meets the criteria for 10060 or 10061. Your only additional consideration involves the level of difficulty of the I&D. There is no specific set of guidelines or criteria that the CPT^® code book outlines in order to report 10061. Rather, you should leave it up to the discretion of your provider, while considering details from the operative report, such as the number of drain placements and the work required for the wound closure.