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Incision and Drainage FAQ

1. What should be documented to determine the appropriate CPT/ICD-10 codes for an incision and drainage (I&D) performed in the emergency department?

The CPT/ICD-10 codes for incision and drainage procedures vary based on factors such as the location, depth, and type of lesion, the presence of complicating factors, multiple lesions, and whether the procedure was simple or complicated.

For accurate coding, the medical record should include the signs/symptoms exhibited by the patient that necessitated the need for an I&D procedure. Additionally, details of the wound, such as pre-procedure size, precise location, and type of lesion (e.g., abscess, paronychia, hidradenitis suppurativa, furuncle, carbuncle, lymphangitis, hematoma, cyst) should be reflected in the ED chart. The procedure note should include details of the procedure, including incision or puncture, amount and quality of drainage, probing and deloculation when performed, and whether the wound was packed, drain inserted, vessel loop placed or left open.

Use care when choosing the correct CPT codes. Some descriptors indicate incision or puncture, while others do not specify the type of approach for a specific location. Similarly, ICD-10-CM diagnosis codes linked to the procedure should accurately reflect the location and type of lesion drained.

2. What is the difference between a simple and complicated I&D?

Complexity of an I&D is determined by the provider. Generally, a complicated I&D may include wound packing, drain insertion, and/or probing and deloculation. Multiple skin or subcutaneous I&D during the same encounter are coded as complicated, rather than coding multiple simple I&D, per CPT.

3. Is ultrasound separately billable when an I&D is performed?

Ultrasound interpretation is a separately billable service frequently used to diagnose and locate a cyst, hematoma, seroma or abscess. Permanent image retention and documented findings related to the reason the study was performed are necessary to capture ultrasound as a separately billable service.  There are ultrasound codes available specifically for soft tissue of the head and neck (CPT 76536) and soft tissue of non-vascular extremity structure (CPT 76882). Additional ultrasound codes are assigned by body area, including abdomen (CPT 76705) or chest/upper back (CPT 76604), and scrotum contents (CPT 76870). Use the -26 modifier to indicate professional component interpretation. If an ultrasound code description does not indicate limited study, a -52 reduced service modifier may be appropriate.   

For additional information, see the ACEP FAQ for Ultrasounds.

4. What are some examples of I&D codes available?

The following list provides some examples of incision and drainage as well as puncture aspiration codes frequently performed in the emergency department: 

10060

Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

10061

Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple

10080

Incision and drainage of pilonidal cyst; simple

10081

Incision and drainage of pilonidal cyst; complicated

10140

Incision and drainage of hematoma, seroma or fluid collection

10160

Puncture aspiration of abscess, hematoma, bulla, or cyst

11740

Evacuation of subungual hematoma

19000

Puncture aspiration of cyst of breast

40800

Drainage of abscess, cyst, hematoma, vestibule of mouth; simple

41800

Drainage of abscess, cyst, hematoma from dentoalveolar structures

46050

Incision and drainage, perianal abscess, superficial

46083

Incision of thrombosed hemorrhoid, external

55100

Drainage of scrotal wall abscess

56405

Incision and drainage of vulva or perineal abscess

56420

Incision and drainage of Bartholin's gland abscess

69000

Drainage external ear, abscess or hematoma; simple

69005

Drainage external ear, abscess or hematoma; complicated

5. How do I bill for follow-up visits after an I&D?

Most incision and drainage or puncture aspiration codes utilized in the emergency department carry a ten (10) day global period. Routine follow-up visits to the same ED, seen by the same provider/group, and limited to re-evaluation of the uncomplicated post-procedural wound may be captured with CPT® 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure). 

If the patient presents during the 10-day global period with additional medical problems or conditions unrelated to the incision and drainage or puncture aspiration (e.g., diabetes or URI), an Evaluation/Management Level may be billed with a -24 modifier to indicate an unrelated E/M service by the same physician or other qualified health care professional during a postoperative period.  

Updated February 2024

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors, or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising from the use of such information or material. Specific coding or payment-related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact Jessica Adams, ACEP Reimbursement Director, at (469) 499-0222 or jadams@acep.org

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