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Dermatology Coding Alert

Reader Question:

I.D. Deep Abscess I&Ds; with This Info

Question: The dermatologist reviews a 29-year-old female patient with complaints of acute pain and tenderness in the area of the wrist. Upon examination, your clinician finds that the area is severely inflamed and is tender. Your clinician diagnoses the patient with a deep abscess not involving the bursa, and he performs an incision to drain the abscess, performs extensive probing to break down loculations, and then cleans and irrigates the wound along with placing sutures and dressings. What code would you use to report the procedure that your physician performed?  

Washington Subscriber

Answer: In this case scenario, you will report 25028 (Incision and drainage, forearm and/or wrist; deep abscess or hematoma) for the incision and drainage procedure that your clinician performed.

The CPT® codes 10060 and 10061 are not the only codes that you have to report an incision and drainage of an abscess. CPT® also has some site-specific codes that you can report when your clinician performs an I&D of an abscess that is located in these specified sites. CPT® guidelines instruct you to report these site specific codes (when available) instead of reporting 10060 or 10061.

There are two site specific codes that you can choose from when your clinician performs an I&D in the wrist:

  • 25028
  • 25031 (…bursa)

Report 25031 when your clinician performs an I&D of the bursa. Since in the case scenario described, your clinician performed an I&D of an abscess deep in the wrist and not an I&D of an infection of the bursa, you should report 25028 and not 25031.