Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forIncision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Paronychia, when sufficiently treated with avulsion of the nail only, should be billed with CPT code 11730 and not as an incision and drainage. Permanent correction of recurring ingrown toenail by nail resection or wedge excision of the nail lip should be billed with CPT code 11750 or 11765 and not as an incision and drainage.Partial or complete avulsion of the toenail is a common treatment for paronychia in association with an ingrown nail. In fact, incision and drainage is not commonly performed for treatment of paronychia in the foot without avulsion of the toenail. This procedure usually effectively drains any associated infection. Therefore, the provider who performs this procedure to address a localized infection should bill the appropriate code 11730, and not one for an incision and drainage service.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.Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request. Then only CPT codes 10060, 10061, 10160 should be used and not combined with CPT codes 11750 or 11765.For Podiatry (Specialty 48):Claims for CPT codes 10060 or 10061 with diagnosis of furuncle/carbuncle (ICD-10-CM code L02.621, L02.622, L02.631, L02.632), suppurative hidradenitis (ICD-10-CM code L73.2) will be subject to review, as these diagnoses are not commonly found in the foot.CPT codes 10060, 10061 or 10160 are payable for ICD-10-CM codes L02.611, L02.612, L98.8 only.CPT code 10140 is payable only for ICD-10-CM codes L76.01, L76.02, L76.21, L76.22, S80.01XA, S80.01XD, S80.01XS, S80.02XA, S80.02XD, S80.02XS, S80.11XA*, S80.11XD*, S80.11XS*, S80.12XA*, S80.12XD*, S80.12XS*, S87.01XA, S87.01XD, S87.01XS, S87.02XA, S87.02XD, S87.02XS, S87.81XA*, S87.81XD*, S87.81XS*, S87.82XA*, S87.82XD*, S87.82XS*, S90.01XA, S90.01XD, S90.01XS, S90.02XA, S90.02XD, S90.02XS, S90.111A, S90.111D, S90.111S, S90.112A, S90.112D, S90.112S, S90.121A, S90.121D, S90.121S, S90.122A, S90.122D, S90.122S, S90.211A, S90.211D, S90.211S, S90.212A, S90.212D, S90.212S, S90.221A, S90.221D, S90.221S, S90.222A, S90.222D, S90.222S, S90.31XA, S90.31XD, S90.31XS, S90.32XA, S90.32XD, S90.32XS, S97.01XA, S97.01XD, S97.01XS, S97.02XA, S97.02XD, S97.02XS, S97.111A, S97.111D, S97.111S, S97.112A, S97.112D, S97.112S, S97.121A, S97.121D, S97.121S, S97.122A, S97.122D, S97.122S, S97.81XA, S97.81XD, S97.81XS, S97.82XA, S97.82XD, S97.82XS.*As allowed by State law.Anesthesia administered by or incident to the physician performing the incision and drainage service is included in the reimbursement for incision and drainage services and is not separately payable.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withintheLCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.The patient's medical record must document the signs/symptoms exhibited by the patient that required the incision and drainage procedure. This information must be available in the patient's record, if requested for review purposes. Additional information such as photographs, operative reports, or progress notes may be required from any provider who demonstrates a pattern of billing repeated incision and drainage services of the same anatomical area.The pre-operative size, location and appearance of any abscess, hematoma or other lesion claimed to have undergone an incision and drainage service must be clearly documented in the medical record.The operative note must include a description of the procedure, e.g. equipment used, and the approximate quantity (e.g., 1 cc, 5 ml) and quality (e.g., serous, sero-sanguinous, bloody, exudative, frank pus, malodorous) of the material drained from the collection.Since the majority of hematomas, seromas and cysts do not require incision and drainage or aspiration, and since this procedure can actually increase the risk of infection, providers reporting these services must document the size, location and quantity of blood, material or serosanguinous fluid drained, as well as the medical necessity of the procedure, (e.g. severe pain or infection and failure to resolve with conservative measures).Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request.The Contractor retains the right to require of select providers photographic documentation of lesions prior to and/or after treatment if there are indications of abuse of any of the codes in this LCD.Providers will be notified of this requirement individually and prior to such a requirement being instituted.If a patient requires incision and drainage services repeatedly (more than once) for treatment of abscess in the same anatomic location, the medical record must clearly reflect the reason(s) for persistent or recurrent infection and what measures are being taken to avoid infections.Utilization Guidelines:A single drainage procedure for most abscesses, hematomas or other collections is often curative. It would be unusual for any individual lesion or collection to require more than two such services. Recurrent fluid or abscess collections or repeated need for incision and drainage services may indicate the need for additional medical or surgical measures to provide definitive treatment.Multiple abscesses or fluid collections in the same patient requiring drainage, more than two times per year in the same location is uncommon. Services exceeding this parameter will be considered not medically necessary. Any claims which include a diagnosis of hidradenitis (ICD-10-CM code L73.2) will be excluded from this parameter. However, the documentation must be clear as to the reason more definitive therapy is not appropriate.