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Local Coverage Determination (LCD)

Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

L33563

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33563
Original ICD-9 LCD ID
Not Applicable
LCD Title
Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/12/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
    290 Foot Care

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

This local coverage determination (LCD) specifies the indications and limitations for incision and drainage services. Incision and drainage is a covered procedure for treating abscesses. Incision and drainage of non-abscess fluid collections is covered when medically necessary due to pain or inflammation. Repeated incision and drainage is not expected, however, in the case of hidradenitis, this may be experienced but the provider must document the reason that more definitive therapy is not appropriate.

Podiatrists are limited in scope of practice by State law. Only those ICD-10-CM codes that are appropriate for the scope of practice will be accepted as reimbursable.

The patient's medical record must contain documentation that fully supports the medical necessity for the incision and drainage as well as a full description of the procedure performed.

Indications:

Incision and drainage or puncture aspiration describes the mechanical task of introducing a sharp sterile instrument into a discrete subcutaneous collection of pus, blood or other fluid for the purpose of removing from the lesion said pus, bacteria, blood, necrotic tissue, or other toxins, to promote resolution of infection, inflammation, and pain or to obtain material for diagnostic analysis.

An abscess is a circumscribed collection of pus of any size in any location, and as such represents an infection. Abscesses usually exhibit one or more of the following clinical findings: redness, warmth, tenderness, fluctuance, edema, lymphangitis. A lesion not exhibiting such signs or symptoms and that does not contain pus or infected purulent fluid is not an abscess, but may be some other type of process requiring incision and drainage such as a hematoma, seroma, bulla or cyst. A simple abscess generally requires only a single puncture or single incision. A complicated abscess with infection and necrosis usually requires more effort to treat. Examples of complicated abscesses are the following: an abscess with 3-4 tracks requiring breaking up of loculated compartments; an abscess requiring undermining of the skin and subcutaneous tissue and extensive laying open of the cavity. In these circumstances, at minimum, locally injected anesthesia is usually required.

Incision and drainage services are covered for treating abscesses (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, post-operative wound infections, or paronychia). Incision and drainage of hematomas, seromas, cysts or other pathologic fluid collections are covered when medically necessary due to pain, inflammation or infection.

Paronychia is an acute or chronic inflammation of the periungual tissues, which may be associated with infection, purulence and granulation tissue. Acute paronychia is treated by relieving pressure on the soft tissues either by packing or by removing a section of nail plate and packing. This usually allows for sufficient drainage to avoid the need for incision and drainage of the soft tissues. This technique is used in the foot with some modifications including the removal of larger sections of nail plate and correction of pathomechanical foot function. However, this technique does not involve the direct incision and drainage of a discrete soft tissue pus or fluid collection and should not be billed as an incision and drainage service. 

Limitations:

Incision and drainage of an abscess is limited to lesions with documented abscess and/or pus collection and is not appropriate for treatment of blisters, cysts (including sebaceous cyst), or other fluid collections without the documented presence of discrete abscess, pus collection, pain, infection or inflammation.

If there is inflammation adjacent to a nail or ingrown nail and the only service provided is trimming the edge of the nail, the incision and drainage codes should not be used. Trimming the nail to prevent recurrence of paronychia is considered to be routine foot care, which has limited coverage.

Incision and drainage services are not payable for treatment of blisters unless there is superinfection with pus and abscess formation.

Providers performing permanent correction of recurring ingrown nail by nail resection (plate, bed, and nail matrix, partial or complete) or by wedge excision of the nail lip, should not bill incision and drainage services. Removal of lytic fragments of the nail plate to relieve symptoms of inflammation without infection of the soft tissues is a routine foot care procedure.
Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information
This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

Other Medicare contractor policies consulted in development of this draft:
  • Empire Medicare Services Carrier LCD (New York [L5096])
  • Empire Medicare Services Fiscal Intermediary LCD (New York [L694])
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
09/12/2019 R9

This LCD was converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.
  • Revisions Due To Code Removal
08/01/2019 R8

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56766. There has been no change in coverage with this LCD revision
  • Provider Education/Guidance
10/01/2018 R7

Due to the annual ICD-10-CM updates, ICD-10 codes T81.4XXA, T81.4XXD, and T81.4XXS have been deleted from Group 1 and the following ICD-10 codes have been added as replacements; T81.41XA, T81.41XD, T81.41XS, T81.42XA, T81.42XD, T81.42XS, T81.43XA, T81.43XD, T81.43XS, T81.44XA, T81.44XD, T81.44XS, T81.49XA, T81.49XD, and T81.49XS. In addition, ICD-10 codes K61.31, K61.39, and K61.5 have also been added to Group 1.

DATE (10/01/2018): At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Revisions Due To ICD-10-CM Code Changes
05/15/2017 R6 ICD-10-CM codes T81.31XA, T81.31XD and T81.31XS were added to the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Practitioner (Part B)
10/01/2016 R5 ICD-10-CM code J34.0 was added to the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Provider (Part A)
10/01/2016 R4 ICD-10-CM codes L76.31, L76.32, L76.33 and L76.34 were added to the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Provider (Part A)
10/01/2016 R3 Due to the annual ICD-10-CM code update for 2017, ICD-10-CM code N61 was deleted from the "ICD-10-CM Codes that Support Medical Necessity" section of the LCD. ICD-10-CM code N61.1 was added as the replacement code. ICD-10-CM code L03.213 was added.

The descriptors were changed for ICD-10-CM codes L76.21 and L76.22.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R2 ICD-10-CM codes M23.000, M23.001, M23.003, M23.004, M23.006, M23.007, M23.011, M23.012, M23.021, M23.022, M23.031, M23.032, M23.041, M23.042, M23.051, M23.052, M23.061 and M23.062 were added to the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R1 ICD-10-CM codes were added for the 7th character for D=subsequent encounter and S=sequela, where the 7th character, A=initial encounter, was already included.
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/05/2019 09/12/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Incision and Drainage
  • Abscess
  • Paronychia
  • Skin
  • Carbuncle
  • Boil

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