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.

Acupuncture

Question:

We are having trouble getting our acupuncture claims paid, can you advise if this is covered per Medicare and other payors? 

Answer:

In general, many payors do not cover acupuncture.  Therefore, it is the patient's responsibility to pay.  Check your payor policies regarding coverage criteria. 

Medicare recently released Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N).  https://www.cms.gov/files/document/mm13288-national-coverage-determination-3033-acupuncture-chronic-low-back-pain.pdf 

CMS will cover acupuncture for chronic low back pain – up to 12 visits in 90 days under the following circumstances: 

• For the purpose of this decision, chronic low back pain (cLBP) is defined as: Lasting 12 weeks or longer; nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); not associated with surgery; and not associated with pregnancy. 

• An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. 

• Treatment must be discontinued if the patient is not improving or is regressing. 

Refer to Medicare’s coverage policy for the type of provider that may furnish the service and for other information. 

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

Cryoablation

Question:

I was told we still need to use the unlisted code 30999 for cryoablation of the nasal nerve.

Answer:

You no longer report cryoablation of the nasal nerve with an unlisted code.  In 2024, a new code was created to report Nasal cryotherapy (31243), also known as nasal cryoablation or cold therapy, as a noninvasive treatment to stop symptoms of chronic rhinitis. 

*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.

Suctioning Debris from the Ear Canal

Question:

I just suctioned debris from the ear canal as there was no impacted cerumen.  Can I still use 69210? 

Answer:

No.  CPT 69210 is specifically for removing impacted cerumen.  There is no CPT code for suctioning an ear canal of debris (e.g., Swimmer’s ear, otitis externa).  You would report an E/M code and you could also report 92504 if you used the microscope to suction the ear canal.  

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

Intradiscal Steroid Injection

Question:

Is there a CPT code for an intradiscal steroid injection for “discogenic pain?”   

Answer:

There is no CPT code for an intradiscal steroid injection. You will report an unlisted code, 22899 or 64999. Most payors consider non-thermal glucocorticoid injections as not medically necessary. Follow your payor policies for reporting unlisted procedures and procedures that may be denied as not medically necessary.  

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