Get the Guidelines for I&D Coding

By Susan Dooley

Incision and drainage (I&D) of cysts or abscesses is a common procedure, but many coders seek CPT
guidelines for abscess coding. CPT offers a number of codes for incision and drainage. To choose the
right code to report, ask yourself three questions. First, what is being incised for example, is it a cyst,
an abscess, or something else? Second, how many incisions are performed? And thirdly, was the
procedure simple or complex?

All About Abscesses

Lets look at possible wound types that might require incision and drainage procedures. Abscesses come
first alphabetically and also happen to come first in the CPT book, with the following two codes:

10060, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or
subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
10061, Incision and drainage of abscess complicated or multiple.

Here, the provider incises the abscess and drains its contents. For simple abscesses, following drainage
the provider will probably leave the incision open without suture closure, allowing it to drain on its own.
Should providers need to place a drain or pack to allow for more extensive drainage, then the procedure
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
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would be classified as complex. By the way, even if your abscess I&D was simple, if more than one
incision is needed, you would report it as a complicated or multiple procedure (10061).

Location, Location, Location

Its important to think about location of the abscess as well. For example, what would you do if your
provider was called upon to aspirate, incise, and drain a peritonsillar abscess? Youd definitely not
report one of the above two codes for this procedure. Peritonsillar means next to a tonsil, those
lymphoid tissues located in the throat. Sometimes acute tonsillitis cases develop this complication. This
procedure has its own CPT code, 42700 (Incision and drainage abscess; peritonsillar).

Incision and Drainage of Cystic Lesions

Cysts are also lesions that can require I&D. These abnormal fluid-filled sacs can occur at varied places
throughout the body. Well consider incision and drainage of a pilonidal cyst. Pilonidal cysts, also
sometimes called pilonidal sinuses, occur when epithelial tissue gets trapped around an ingrown hair in
the area above the buttocks. A sinus cavity develops and sometimes includes a fluid-producing cystic
lining.
Determining which CPT code to report depends upon the providers documentation, as always. If it
specifically states pilonidal cyst, or if the location is provided clearly enough that you can make that
conclusion, youd report either of the following:

10080, Incision and drainage of pilonidal cyst; simple

10081, Incision and drainage of pilonidal cyst; complicated.

A complicated I&D of these cysts translates to a difference of about $90 from the payment for the
simple I&D, so youll want to make sure you can tell the difference. In the documentation, look for
description of cyst depth and whether the cyst had multiple sinus tracts. If the cyst is more superficial,
or the lesion is not severely infected, youd want to report the simple I&D code. You can also scour the
documentation for description of the type of closure your provider performed. If a simple closure or no
closure at all was done, youd likely report 10080 for the simple procedure. But if the documentation
describes a cyst located deeper in the subcutaneous layers, or if it was severely infected, youd probably
report 10081 for the complicated procedure. Similarly, a layered closure and/or a surgical site treated
with wound packing would also clue you in to report the code for the complicated procedure.

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The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com