Kelly Posted Thu 20th of December, 2018 12:17:53 PM
What are the documentation requirements for CPT code 10060? Must the documentation state, "...incision..." for an I&D of rt great toe?
SuperCoder Answered Fri 21st of December, 2018 05:41:45 AM
Thank you for your Question.
Incision and drainage or puncture aspiration describes the mechanical task of introducing a sharp sterile instrument into a discrete subcutaneous collection of pus, blood or other fluid for the purpose of removing from the lesion said pus, bacteria, blood, necrotic tissue, or other toxins, to promote resolution of infection, inflammation, and pain or to obtain material for diagnostic analysis.
An abscess is a circumscribed collection of pus of any size in any location, and as such represents an infection. Abscesses usually exhibit one or more of the following clinical findings: redness, warmth, tenderness, fluctuance, edema, lymphangitis. A lesion not exhibiting such signs or symptoms and that does not contain pus or infected purulent fluid is not an abscess but may be some other type of process requiring incision and drainage such as a hematoma, seroma, bulla or cyst. A simple abscess generally requires only a single puncture or single incision. A complicated abscess with infection and necrosis usually requires more effort to treat. Examples of complicated abscesses are the following: an abscess with 3-4 tracks requiring breaking up of loculated compartments; an abscess requiring undermining of the skin and subcutaneous tissue and extensive laying open of the cavity. In these circumstances, at minimum, locally injected anesthesia is usually required.
Incision and drainage services are covered for treating abscesses (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, post-operative wound infections, or paronychia). Incision and drainage of hematomas, seromas, cysts or other pathologic fluid collections are covered when medically necessary due to pain, inflammation or infection.
Incision & Drainage CPT Codes Documentation
The following documentation must be present in the medical record:
- A detailed description of the abscess (location, signs/symptoms, appearance, size, etc)
- Patient must be prescribed a topical antibiotic or an oral antibiotic or other medicament for the same
- Use of incision and drainage of abscess codes (CPT codes 10060, 10061) is limited to lesions with documented abscess and/or pus collection.
- Use of these codes is not appropriate for treatment of blisters, cysts (including sebaceous cyst), or other fluid collections without the documented presence of discrete abscess, pus collection, pain, infection or inflammation.
- Billing for incision and drainage procedures (CPT codes 10060, 10061, 10160) for treatment of paronychia of the foot when avulsion or resection of the toenail has been performed to treat the same condition, is not appropriate.
- A culture and sensitivity test must be performed of the puss (puss is assumed in an I&D procedure)
Hope this helps!