ACEP ID:

Incision and Drainage FAQ

  • What should I document for an incision and discharge (I&D)?

    Recommendations
    Answer

    Documentation for an incision and drainage or puncture aspiration should include precise location, the type of lesion (e.g. abscess, paronychia, hidradenitis suppurativa, furuncle, carbuncle, lymphangitis, hematoma, cyst), a description of the procedure to include whether incision or puncture, amount and quality of drainage, probing and deloculation when performed, and whether wound was packed, drain inserted or left open.

    Use care 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.

    Answer

    Documentation for an incision and drainage or puncture aspiration should include precise location, the type of lesion (e.g. abscess, paronychia, hidradenitis suppurativa, furuncle, carbuncle, lymphangitis, hematoma, cyst), a description of the procedure to include whether incision or puncture, amount and quality of drainage, probing and deloculation when performed, and whether wound was packed, drain inserted or left open.

    Use care 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.

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

    Recommendations
    Answer

    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®.

    Answer

    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®.

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

    Recommendations
    Answer

    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 https://www.acep.org/administration/reimbursement/reimbursement-faqs/ultrasound-faqs/.

    Answer

    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 https://www.acep.org/administration/reimbursement/reimbursement-faqs/ultrasound-faqs/.

  • What are some examples of I&D codes available?

    Recommendations
    Answer

    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

     

    Answer

    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

     

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

    Recommendations
    Answer

    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 (eg, 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 post-operative period.  

    Example:  Patient returns 3 days after I&D of abscess RT axilla. Packing removed, wound healing without erythema or drainage, fresh dressing applied. Patient complains of cough for past 12 hours. Chest x-ray clear, prescribed Promethazine-DM for cough. 

    L02.411

    Z48.01

    99024

    R05

    99283-24,25

     

     

    Answer

    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 (eg, 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 post-operative period.  

    Example:  Patient returns 3 days after I&D of abscess RT axilla. Packing removed, wound healing without erythema or drainage, fresh dressing applied. Patient complains of cough for past 12 hours. Chest x-ray clear, prescribed Promethazine-DM for cough. 

    L02.411

    Z48.01

    99024

    R05

    99283-24,25

     

     

Updated March 2021

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 out of 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 David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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