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Detailed Clinical Documentation Crucial for Accurate Abscess Coding

by | Oct 21, 2016 | Medical Coding News, Resources | 0 comments

The most common skin and soft tissue infections that family physicians treat are superficial and small abscesses. When it comes to assigning the CPT codes, two key pieces of information are required:

  • The location of the abscess
  • The method of treatment, such as, incision and drainage (I&D), excision

Depending on the nature of the abscess, the approach used for the treatment could be open or percutaneous. Uncomplicated purulent soft tissue abscesses in easily accessible areas without overlying cellulitis can be treated with I&D only. One of the following codes is used to code incision and drainage of a superficial skin abscess:

  • 10060 – incision and drainage of abscess; simple of single or for a small collection of purulent material (such as infection that is limited to the superficial subcutaneous tissues)
  • 10061 – incision and drainage of abscess; complicated or multiple

A complicated I&D would involve:

  • Multiple incisions
  • Drain placements
  • Probing to break up loculations
  • Extensive packing, or
  • Subsequent wound closure

However, the American Medical Association does not provide any guidance in the CPT guidelines to help determine if the abscess is simple or complicated. To avoid undercoding, physicians who rely on medical coding services should provide detailed documentation on the following:

  • Whether the abscess is superficial or deep
  • The location of the abscess

For below the fascia, coding has to be specific with regard to locations such as bone, tissue-Abdomen, tissue-Nasal, etc. In the case of a deep abscess below the fascia, rather than simply reporting 10060-10061, a code to describe a more extensive procedure would be needed. Here are some examples:

  • 20005 – Incision and drainage of soft tissue abscess, subfascial (involves the soft tissue below fascia)
  • 28002 – Incision and drainage below fascia, with or without tendon sheath involvement, foot; single
  • 28003 – Incision and drainage below fascia, with or without tendon sheath involvement, foot;
  • 28005 – Incision, bone cortex (e.g., osteomyelitis or bone abscess), foot
  • 21502 – Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy

Family physicians can lose a significant amount of revenue due to undercoding. The bottom line when it comes to abscesses is that the physician’s notes should clearly describe the appearance and signs and symptoms so that it can be determined if the abscess is simple or complex, as well as support the treatment that was provided. Expert medical coders in professional medical coding companies work closely with providers to ensure the quality of their documentation and optimize family practice medical billing practices and collections.