Wiki aspiration attempt

[LuckyLily]

I'm trying to figure out if this procedure can be charged with a 10160. Nothing was aspirated.

Cutaneous abscess on the nape of his neck. This was palpated and was found to be nonfluctuant and indurated. Needle aspiration was performed to rule out an abscess that required drainage. Skin was anesthetized with 1 mL of 1% lidocaine with epinephrine. An 18-guage needle was placed into the infected area, and no pus was aspirated. I will start patient on Septra.

Some documentation that I can keep in my notes would be greatly appreciated.

 

[JenniferB7]

You are right. Because there was no aspiration, you cannot bill CPT 10160.

CPT Assistant Archives (April 2010) advises you to bill an E/M service in this instance:

April 2010 page 10
Surgery: Integumentary System (Q&A)

Question: Would it be correct to report CPT code 10060, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single, when a physician uses a needle to puncture an abscess that is allowed to drain by itself, without any incision or aspiration of the abscess into the syringe?

Answer: No. CPT code 10060, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single, includes both the incision and drainage of an abscess, therefore, it would not be appropriate to report this code because there was no incision involved. Also, it would be inappropriate to report code 10160 (puncture aspiration of an abscess) since no aspiration was performed. If evaluation and management (E/M) services were rendered, such as services described in code 99211, this would be used to report the service. Report the appropriate E/M services based on the key components provided.

Surgery: Integumentary System (Q&A)(April 2010). CPT�® Assitant. 2010; April 2010 page 10​

Hope that helps!

Sincerely,

Jennifer M. Connell, CPC, CENTC, CPCO, CPPM, CPMA, CPC-P, CPB, CPC-I

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[Mohamed Sajjad Hussain]

why we can't apply with 52 which means to be reduced services ,10160-52

 

[Lisablawusch]

Technically, this should be full 10160 code. Just because a procedure was "unsuccessful" does not mean the procedure wasn't done. Full procedure was performed. Full procedure should be charged.