Incision and Drainage (I&D)

Question:

My physician wants to know the difference between a simple and complicated I&D.  I cannot find any specific guidance.

Answer:

A simple or single I&D includes drainage of the pus or purulence from the cyst or abscess. The physician leaves the incision open to drain on its own, allowing for healing with normal wound care. A complex I&D includes placing a drainage tube to allow for continuous drainage or packing to facilitate healing. In certain cases, tissue excision, primary closure, and/or Z-plasty may be required. CPT code 10060 is a simple or single I&D and is typically reported when an abscess or cyst is opened with a surgical instrument, allowing the contents to drain. The lesion may be curetted and irrigated. CPT 10061 often involves larger abscesses requiring probing to break up loculations and packing to promote ongoing drainage. 

You should report CPT code 10060 for incision and drainage of a simple or single abscess and CPT 10061 for complex or multiple cysts. Complex or multiple cysts may require surgical closure at a later date. 

*This response is based on the best information available as of 6/6/24.