Simple VS Complicated Incision and Drainage
The provider makes an incision over the abscess into the abscess cavity and allows it to drain, during an incision and drainage (I&D). It may be left open allowing the continuation of drainage, loculations may be broken up using a surgical clamp, and/or the wound may be packed with gauze.
The difference between a simple and complicated I&D is, a complicated I&D would contain:
- Multiple incisions.
- Drain placements.
- Probing to break up loculations.
- Extensive packing or
- Subsequent wound closure.
The CPT Book provides two codes for Incision and drainage of a superficial skin abscess:
- 10060 Incision and drainage of abscess; simple of single
- 10061 Incision and drainage of abscess; complicated or multiple
CPT(R) Assistant states, ?an incision must be performed and documented to bill for this procedure. If the provider uses a needle to puncture the abscess, and lets it drain, it is not appropriate to use the incision and drainage codes. This procedure would be included in the Evaluation and Management of the patient for the day and not separately reported.
Unfortunately, there isn?t any guidance in the guidelines or from the AMA in the form of a CPT(R) assist to help determine simple versus complicated. The only key to ensure correct coding for the superficial abscess codes is through proper communication. The provider/physician must be educated with documentation tips. It is very important that the provider needs to document if the abscess is superficial or deep. One also needs to know the location because if the abscess is deep, code choice is based on the location of the abscess and is not dependent simply on single versus multiple, and simple versus complicated. Appearance and signs and symptoms can assist with determining simple versus complex. One must make sure that the provider documents the details needed to support the service that is provided.