An incision and drainage procedure as the name implies involves making an incision into the body and draining fluid from the body. This fluid drained can be an area of infection such as an abscess or it may be an area of hematoma or seroma.
At first glance, coding incision and drainage procedures looks pretty straightforward (there are just a handful of codes for incision and drainage in the integumentary section of the CPT manual). Not all incision and drainage procedures should be coded with these codes from the integumentary section though. There are incision and drainage codes throughout the surgery section of the CPT manual that are designed to represent deeper incision and drainage procedures for various locations throughout the body. Let’s start by looking at the incision and drainage procedure in the integumentary section of CPT.
Incision and Drainage of Infection
CPT codes 10060 and 10061 include an incision and drainage of an area of infection other than postoperative infections which we will discuss later. If we look at the examples in parentheses in the descriptions for these codes in the CPT manual, we can see that an incision and drainage of a carbuncle, hidradenitis, a cyst, a furuncle, paronychia, and cutaneous and subcutaneous abscesses can be reported with these codes. So what makes 10060 and 10061 different from each other? CPT 10060 includes a “simple” or “single” incision and drainage and 10061 includes a “complicated” incision and drainage or “multiple” incision and drainages.
This brings us to another questions: how are simple and complicated defined for these codes? The AMA addressed that question in their CPT Assist publication in December of 2006. The AMA stated that the CPT manual itself does not provide definitions for simple and complicated and that the code chosen is based on the physician’s judgment about the degree of difficulty involved in the incision and drainage procedure. So as coders, how do we pull out that detail from an operative report since we are not the physician making that judgment? I look for keywords that support the fact that the incision and drainage was complicated. I look for terms like “complex”, “complicated”, “difficult/difficulty”, “extensive”, and “multiple loculations” (meaning the physician had to enter into multiple pockets of the same abscess to completely drain it). An additional clue that the incision and drainage is more complicated than average can include placing a drain into the abscess cavity to allow the infection to continue to drain after the surgery is finished (this is not typical unless there’s an extensive infection present). Finally, the incision and drainage of multiple abscesses would always be considered complicated. For example, if the patient has an abscess on the right wrist and an additional area of abscess further up on the right forearm and the physician incises and drains both abscesses, this is a complicated incision and drainage that qualifies for CPT 10061. If none of these details that suggest a complicated incision and drainage are documented, we would instead code a simple incision and drainage or 10060.
If the physician is performing an incision and drainage procedure in the skin or subcutaneous tissues, but he is draining something other than an area of infection described by CPT codes 10060 and 10061, we need to look at other available codes in the integumentary section of the CPT manual:
Incision and Drainage of Hematoma/Seroma
CPT 10140 includes an incision and drainage of hematoma, seroma, or another “fluid collection” in the skin and subcutaneous tissues.
Incision and Drainage of Pilonidal Cyst
CPT codes 10080 and 10081 include incision and drainage of a pilonidal cyst.
- CPT 10080 is for a “simple” incision and drainage of a pilonidal cyst.
- CPT 10081 is for a “complicated” incision and drainage.
- Our lay description of these procedures which can be found in resources such as Encoder Pro or the Coder’s Desk Reference tells us that simple incision and drainage procedure are typically left open to heal on their own or packed with gauze while complicated incision and drainage procedures for pilonidal cysts involve marsupialization of the cyst or closure of the area with sutures
Incision and Drainage of a Postoperative Infection
CPT code 10180 is reported for incision and drainage of a complex postoperative infection. The circumstances under which the infection formed (as a result of a prior surgery) lead us to use this code rather than codes 10060 and 10061 which include incision and drainage of other infections.
Incision and Drainage Below the Skin and Superficial Subcutaneous Tissue
All of the codes we have discussed so far are for incision and drainage procedures of the skin or the superficial subcutaneous tissues. So what if the incision and drainage procedure involves draining an area that is deeper than the skin and subcutaneous tissues (e.g., fascia, muscle, bone, a joint, or an internal organ)? That’s where the incision and drainage procedures throughout the surgery section of the CPT manual come in. When searching for an incision and drainage code, don’t limit yourself to only those codes in the integumentary section if the incision and drainage is of a deeper organ or structure. Always begin your search in the index of the CPT manual by looking up the term “incision and drainage.” From there, you can find “what” was drained (e.g., abscess) or “where” in the body the incision and drainage occurred. If there is more than one code that could fit, read the lay description for each potential code to see which code fits best.
For example, let’s say we have a note where an incision and drainage is performed of an abscess in the muscle overlying the right elbow. The incision is carried down to the muscle where the abscess is encountered and drained. If we look up incision and drainage in the index of the CPT manual and then go down to the location of “elbow” we have two possible codes: 23935 and 24000. If we read the CPT code description and the lay description of CPT 23935, we see that this code represents incision and drainage of an abscess of the bone and requires opening into the bone cortex. Because our example involves an abscess in the muscle which is more superficial than the bone, CPT 23935 is not the correct code. If we look at the CPT code description and lay description of CPT 24000, we see that this code requires an arthrotomy or an incision into the elbow joint capsule itself. Because the abscess in our example is in the muscle and did not require the surgeon to incise into the joint itself, CPT 24000 is also not the correct code. So we have now checked every option underneath the location of “elbow” for incision and drainage procedures in the CPT index. So where do we go from here? Now we need to see if looking up “what” was drained gets us to a better code. Instead of going to “elbow” under incision and drainage, this time, let’s go to “abscess.” Underneath the term “abscess” we have another entry for “elbow” and this time we are directed to CPT 23930. This code per its CPT description says it is for incision and drainage of a “deep abscess or hematoma.” If we then read the lay description of the code, we see that the physician has to carry his incision down through the deep subcutaneous tissues and possibly into the muscle or fascia depending on the depth of the abscess or hematoma. When he exposes the abscess or hematoma in the deep subcutaneous, fascia, or muscle layers he then incises into the abscess or hematoma and drains it completely. Based on this description and the details in our example with the abscess being drained in the muscle, CPT 23930 fits and is the correct CPT code for this case.
You can follow the steps above for incision and drainage procedures throughout the body including the internal organs. Be sure to check the CPT code description and lay description of all of the possible code choices for “where” your incision and drainage occurred and “what” was drained in order to select the most accurate code.
