Basics of Abscess Coding
Abscess Coding procedures, you will need at least two pieces of information about the abscess, the location and the treatment method, eg incision and drainage, excision.
In some cases, you also may need to know the approach (Open, Percutaneous) the provider uses during treatment.
For incision and drainage (I&D) of superficial abscess or abscess of the skin at any location, 10060 Incision and drainage of abscess (Eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia); simple or single or 10061 complicated or multiple must be reported.
As specified in the code descriptors, 10060 for single abscess, or for a small collection of purulent material (e.g., paronychia, or a small cyst around a hair follicle), must be reported. In such a case, the infection is limited to the superficial subcutaneous tissues. For I & D of multiple abscesses, or of a single large or ?complicated? abscess, 10061 must be reported. The determination of simple/single vs. complex/multiple is the physician?s, and must be supported by the available documentation. If documentation is not clear, the physician should be asked for documenting in detail.
For abscesses below the fascia, coding is much more specific. To select an appropriate code to describe ?internal? abscess, check the CPT(R) index under the main term ?abscess.? Do not code directly from the CPT(R) index. Rather, confirm your code selection by referencing the full code descriptor in the tabular portion of the codebook.
Within the musculoskeletal section of CPT(R), there is a general incision code (20005 Incision and drainage of soft tissue abscess, subfascial (ie., involves the soft tissue below the deep fascia), as well as codes specific to: neck, shoulder, upper arm and elbow, forearm and wrist, hand and fingers, pelvis and hip joint, femur and knee joint, leg and ankle joint, and foot and toes. For example, for I&D of a below the fascia abscess of the foot, any of the following may apply:
? 28001 Incision and drainage, bursa, foot
? 28002 Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space
? 28003 Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas
? 28005 Incision, bone cortex (E.g: Osteomyelitis or Bone abscess), foot.