Incision and drainage services
Incision and drainage (I&D) is a common procedure for an abscess or cyst that may contain pus.
This procedure is performed by :
? Locally anesthetizing the area surrounding the abscess.
? A scalpel or needle is then inserted into the skin and the purulence is drained.
Incision and drainage is a minor surgical procedure that usually can be performed in the office setting by a physician, nurse practitioner or physician assistant
CPT(R) classifies Incision and Drainage in different sections of the book based on the anatomic site. Among the most common codes and/or categories are:
? 10060-10061 abscesses
? 10080-10081 cysts
? 10140 hematoma,
? 10180 complex wounds
? Under-coding I&D?s may lead to revenue loss, while over-coding can trigger an audit. To code Incision & Drainage appropriately, follow three simple steps:
? Proper identification of the site requires the coder to be familiar with anatomy.
? An abscess contains pus and is usually left to drain. A cyst is removed together with its epithelial lining. Hematoma is a collection of blood outside a blood vessel. A seroma is a collection of serum in the body, producing a tumor like mass.
? Some I&D procedures in the CPT(R) book are identified as either ?simple? or ?complicated.? For example:
Incision and drainage of pilonidal cyst; simple 10080 or complicated 10081
It is important for physicians to document and differentiate whether a simple or complicated procedure was performed.
A simple Incision & Drainage includes:
? Drainage of the pus or purulence from the cyst or abscess.
? The physician leaves the incision open to drain on its own, allowing for healing with normal wound care.
A complex Incision & Drainage includes:
? Placement of a drainage tube to allow for continuous drainage or packing facilitating healing.
? In certain cases, tissue excision, primary closure, and/or Z-plasty may be required.
Examples Light the Way to Proper Coding
When coding, it?s important to identify the correct section to use in CPT(R). The following examples show that it is easy to consider coding only from the integumentary system using procedures codes 10060-10180, yet the procedure may be more appropriately described in a different section.
Example A
A patient comes for examination with an infected right eyelid abscess, swollen and tender. After informed consent is received, the area is injected with 0.2 cc of 2 percent Lidocaine. An incision is made with a No. 18 needle to allow good drainage. The patient is given Ciprofloxacin for postoperative measure.
In this case, 67700 i.e Blepharotomy, drainage of abscess, eyelid appropriately represents the procedure, although the coder had chosen 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single.
Example B
After receiving a signed, informed consent by the guardian, a 12-year-old boy undergoes Incision & Drainage of an infected hematoma in the right external ear canal. A No. 15 blade is used to make an incision into the hematoma and express purulence , following adequate anesthesia of the overlying hematoma?s skin. Patient tolerates the procedure well and is instructed to continue with an antibiotic and follow up within a week.
In this case, the correct code is 69000 Drainage external ear, abscess or hematoma; simple. The coder instead chose 10060, which would lead to lost revenue.
If the physician had documented that a drain or packing was placed or applied to the area, it would be appropriate to code 69005 Drainage external ear, abscess or hematoma; complicated.
Example C
A patient with an infected Bartholin?s cyst undergoes Incision & Drainage after appropriate prepping and anesthesia is performed. The area is packed with Betadine gauze and sutured in place. The patient is placed on doxycycline. The appropriate CPT(R) is 56420 Incision and drainage of Bartholin?s gland abscess. Note that placement of drain is included in the procedure and not separately coded. There is no separate procedure code for a complex Incision & Drainage of Bartholin?s cyst.
The significance of communication between the provider and coder is very important. When the documentation is not clear and precise, clarifying with the rendering physician before choosing a code would be a preferred standard. Educating the physicians on proper documentation will save the practice from unnecessary appeal process, amending documentation, and rebilling. It will also help you pick the accurate code for appropriate reimbursement. Physicians are usually focused on the clinical aspect of providing care and many times are unaware how non-specific or improper documentation may impact proper coding and reimbursement.
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