The Coding Sleuth 15
by Tara Conklin
Incision is made, abscess is drained, and sutures are applied; easy right? Not quite Quick Draw. Don’t be so quick to apply that popular I&D code 10060 for all abscesses and hematomas. There is much more below the surface that is often over looked. Grab your coding hat and let’s check out the scene.
There are many factors that must be considered when coding an incision and drainage of the skin and muscle. Oh sure there are your internal I&D procedure such as for peritoneal abscesses but these are a whole different banana all together. Most of the confusion (and miscoding) comes from those conditions that occur in the skin, subcutaneous tissue and muscle. For this reason we’ll concentrate our investigation here.
The first thing to take note of is what exactly we are dealing with; is it a cyst, an abscess, a hematoma or some other fluid collection? How did it come about; is it post-operative, traumatic, an infection or non-healing wound? Where is it located and what structures are involved; joints, muscles, localized tissue or skin?
These are all clues that will help us solve this perplexing puzzle.
An incision and drainage is far different from a puncture aspiration. An I&D involves exactly that, an incision. How far down the incision goes offers assistance in where to get our codes. A skin or subcutaneous abscess goes no further than the first, second and third layers of the skin. A simple I&D is reported with 10060. If the abscess is complicated in any way or there are multiple abscesses we code 10061. However this is only coded once regardless of the number of I&Ds performed, even if they are considered simple. Do not code 10060 multiple times for more than one simple abscess.
You may think these are the only two codes for skin or tissue drainage, but guess what, you’d be wrong. What!? You say you don’t believe me? Well then I say, have faith my friend it’s true. Come, turn your pages and look at the first two codes in the musculoskeletal section of your CPT and tell me, what do you see? Go ahead, I’ll wait…………….…..OH look at that... See there are not one but two codes for soft tissue abscesses. 20000 and 20005 both report soft tissue abscess incisions. 20000 reports superficial or only involving layers of the skin and 20005 for deep or complicated. 20005 may involve the underlying muscle, fascia (that’s the protective layer of fibers covering the muscles) or even to the bone. Okay, so you say you see the difference between 20005 and 10060 for complicated, but how do you know when to use 10060 and 20000? HEY that’s a good question! Now you’re thinking.
20000 & 20005 are much more involved than a direct incision and drainage. Look for exploration of the abscess cavity, debridement of the necrotic tissue and skin in your report and these both involve drainage. In 20005 the physician may go all the way down to the bone and may actually remove dead bone often found in osteomyelitis. This condition is included as an example in the code descriptors but don’t mistake it for the only underlying condition, it’s a guideline. Abscess codes from the 682 ICD category are also applicable here.
Code 10180 reports I&D of a postoperative wound infection because these are usually more complex than a simple drainage and can involve removal of necrotic skin, sterile packing and even be left open to drain. Closure can be done at the time of drainage or later after adequate drainage. If these additional procedures are not done or simple drainage is performed use 10060.
For a hematoma or better known as a bruise on the skin, use code 10140.
The rest of the codes we are going to look at are also found in the musculoskeletal section of the CPT. Oh yes there are many more found here and they come with a much fatter purse. See you like to hear things like that right? Yeah I see you grinning don’t try to hide it.
Finding these codes is actually pretty simple even without the use of your Index. All you have to know is how the section is structured. The codes in this section being with the first two I&D codes which we have already discovered, 20000 & 20005. After all the extra “stuff” found in the beginning of this section we start with procedures in the head and work our way down to the toes. The first subsection in each anatomical category is …what else… Incision. What a great place to find incision and drainage codes. But hey... wait a minute there are no I&D codes in the head. Well silly how thick is the skin up there on your noggin anyway. We’ve all heard the saying “thick headed” well I think it’s safe to say we’re not talking about the depth of the skin. Then there’s the whole issue of “deep”. You go any deeper than the skin and you’ve gone from “thick headed” to “hard headed”. To go any deeper you would need a drill and to be pretty good in lobotomies. Safe to say no I&D’s here.
So let’s move down to the spine. Oh voila our first two codes are 22010 I&D, open, of deep abscess posterior (back) spine, cervical, thoracic or cervicothoracic and 22015 lumbar, sacral or lumbosacral .Looking at these codes we’ll use them as a guide. First, all the I&Ds in this section are for “deep” abscesses OR hematomas. These also include deep postoperative seromas and infections.
These procedures may involve deep subcutaneous conditions that are open on the skin, or they may lie below the skin and the physician must open the skin up in order to gain access to the abscess deep in the structure. This brings us to another major aspect of these procedures. They normally involve a deeper incision or tissue dissection and more than a local anesthetic. These often require a regional and not uncommonly general anesthesia, especially if going down to bone. Hello, put me out!
They can also be used for bursa of the joints.
The incision may be extended if the mass is larger than initially expected. The contents are drained, the area is irrigated and the incision is either repaired, closed with drains in place or simply left open until closure at a later time.
Let’s look at the difference in reimbursement on these. Now you know the codes and what to look for in your report we can get a better look at what the possible reimbursement might look like. First off, if you are one of those coders that didn’t know any better and has used 10060, 10061 and 10140 for all of your I&D procedures, please sit down and you may want to have someone on standby to drive you home.
Let’s say your physicians (or you for the physicians who read our newsletter) he performs all his procedures at the hospital or surgery center It’s safe to say the majority of the mistakes are made with 10160 since you may look at the report and see the physician had to go all the way down to the fascia to drain a rather large abscess of the thigh.
This looks pretty complicated so you have been reporting 10160. This has a current (2006) reimbursement of $149.47, respectable for an hour’s work right? Well armed with the new information we realize for our example, this particular report falls more appropriately under code 27301 I&D of deep abscess, this or knee region. This carries a current (2006) reimbursement of… are you breathing…. $456.30. That’s three and a half times the amount of 10160. It’s okay, take a deep breath, slow in and slow out. Do you need the smelling salts?
I won’t tell you how much the hip and pelvis code pays.
Bill out four of these reports, and that’s the difference between staying four nights at the Ramada Inn and four nights at the Ritz-Carlton.
Bottom line… know your reports and know your codes. These procedures are similar to the game of “limbo”, just ask yourself “how low did he go?” Or in this case how deep? What kind of condition are you dealing with, where did it start and how. There are at least a 100 I&D codes in the CPT. Knowing your location and your “sonar” depth are the keys to solving this puzzle.
Until next time… happy coding!
--Tara