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.

Mohs Surgery Documentation

Question:

What should be documented to support medical necessity for Mohs surgery? 

Answer:

The patient should have a confirmed pathology report.  Specific criteria must be documented: type of cancer, location, size, and other factors (healthy, immunocompromised, aggressive, etc.) for coverage.  The medical records should clearly show that Mohs surgery was chosen because of the lesion's complexity, size and location and why other approaches are not medically necessary and reasonable. The operative notes and pathology documentation in the patient's medical record must clearly show that Mohs micrographic surgery was performed using the accepted Mohs technique, with the same physician performing both the surgical and pathology services. The notes should also contain the location, number, and size of the lesion(s), the number of stages performed, and the number of specimens per stage. The Mohs surgeon must describe the histology of the specimens taken in the first stage. That description should include depth of invasion, pathological pattern, cell morphology, and, if present, perineural invasion or the presence of scar tissue. For subsequent stages, you may note that the pattern and morphology of the tumor (if still seen) are as described for the first stage; if differences are found, note the changes.  Some payors have additional requirements to support the medical necessity of Mohs.  It is important to check payor policies to ensure compliance with the payor.

*This response is based on the best information available as of 5/23/24.

Soft Tissue Tumors

Question:

I excised a 1 cm lipoma from the patient’s scalp and reported CPT code 21011. I also performed an intermediate repair of 1.4cm and reported CPT 12031. I submitted the claim to the insurance company, and they denied the repair. Why can’t I get paid for the repair? Is the CPT code I submitted incorrect?

Answer:

When a soft tissue tumor excision is performed, the direct closure (simple or intermediate repair) is included in the soft tissue tumor excision and cannot be reported separately. According to CPT Assistant February 2010; a complex repair may be reported when extensive undermining or other techniques are used to close the defect and the elevation of tissue planes to permit resection of the tumor is included in the soft tissue tumor excision. Adjacent tissue transfer, split-thickness/full-thickness graft, muscle flap, etc. may also be reported separately. Keep in mind, though, that some payors may include the complex repair as payment for the soft tissue tumor excision.

Source: CPT Assistant February 2010

*This response is based on the best information available as of 5/9/24.

Post Operative Infection

Question:

What CPT code would I use for an I&D of a complicated postoperative wound infection?

Answer:

The correct CPT code is 10180 (Incision and drainage, complex postoperative wound infection).

*This response is based on the best information available as of 4/25/24.

Destructions

Question:

What CPT code should I bill for the destruction of seborrheic keratosis? My physician told me to bill 17000 and 17003 for additional destructions.

Answer:

CPT codes 17000 and 17003 are used to report actinic keratosis (AK) destruction, not seborrheic keratosis (SK) destruction(s).  The correct codes are 17110 for up to 14 lesions, and 15 or more lesions are reported with CPT code 17111. Make sure the documentation includes the type of lesion, the number of lesions destroyed and the site of each lesion.

*This response is based on the best information available as of 4/11/24.

Biopsy of Eyelid

Question:

Can I use CPT code 11106 for an incisional biopsy of the eyelid? 

Answer:

An incisional biopsy of the eyelid is not reported with CPT code 11106 but is reported with CPT code 67810 (biopsy of the eyelid).

*This response is based on the best information available as of 3/28/24.