Know When to Assign Site-Specific I&D Codes
Question: A patient presented to an outpatient surgical clinic complaining of worsening perianal pain, which was more agonizing with sitting and defecation. A physical examination under local anesthesia shows a 4 cm tender, fluctuant, erythematous swelling at the 5 o’clock position, 1.5 cm from the anal verge. There is no induration extending into the ischiorectal space. The surgeon made a cruciate incision and expressed approximately 15 mL of purulent material. The physician also probed the cavity to break up any loculations and did not identify any fistulas. My colleague thinks we should assign incision and drainage (I&D) code 10061 because the physician broke up loculations, but I feel like there is a more appropriate code. Can you help? Alabama Subscriber Answer: The CPT® code book does have a more appropriate code for this case. Assign 46050 (Incision and drainage, perianal abscess, superficial) to report this procedure. This code is designated for reporting the I&D procedure on an abscess located in the perianal area. Code 46050’s descriptor specifies that the code covers a superficial perianal abscess procedure. Be specific: Generic integumentary I&D codes, such as 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) and 10061 (… complicated or multiple), describe I&D procedures of cutaneous and subcutaneous abscesses. These codes are the default code options when more specific codes do not exist in the CPT® code book. You should report site-specific I&D codes over generic integumentary I&D codes when the site-specific procedure codes exist. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
