This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33909 Incision and Drainage of Abscess of Skin, Subcutaneous and Accessory Structures. Please refer to the LCD for reasonable and necessary requirements.
Coding Guidance
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Procedure codes 10060 and 10061 represent incision and drainage of an abscess involving the skin, subcutaneous and/or accessory structures. Therefore, the medical necessity diagnosis code must represent an abscess, not the underlying condition causing the abscess. For example, the ICD-10-CM code for sebaceous cyst would not meet medical necessity for procedure codes 10060 or 10061. If the patient had an abscess of a sebaceous cyst then it would be appropriate to code the applicable ICD-10 CM code for the abscess (depending upon the anatomical location of the abscess).
Similarly, if billing a covered diagnosis, the medical record must demonstrate that an abscess was present. For example, if billing the diagnosis code for paronychia of the toe (ICD-10 CM code L03.031-L03.39), the medical record must clearly demonstrate that an abscessed paronychia was present and that incision and drainage of the purulent material occurred, in order to bill procedure code 10060 or 10061. If a nail avulsion occurred and the medical record documentation does not demonstrate that an abscess was present and incision and drainage of purulent material occurred, then the appropriate nail avulsion procedure code (11730 or 11732) should be billed, not procedure codes 10060 or 10061.
Furthermore, there are many other anatomical sites of abscess that are not addressed in this policy. There are numerous incision and drainage procedure codes that are specific to the incisions and drainage of an abscess in various anatomical sites. Therefore, it would be appropriate to bill these more specific incision and drainage codes. For example: an abscess of the eyelid should be billed with procedure code 67700 (Blepharotomy, drainage of abscess, eyelid); a perirectal abscess should be billed with procedure code 46040 (Incision and drainage of ischiorectal and/or perirectal abscess); an abscess of the finger should be billed with procedure codes 26010-26011 (Drainage of finger abscess).
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- The medical record must clearly indicate that an abscess was present. This should include the location, size, and appearance of the abscess.
- If frequent incision and drainage is required, the medical record must reflect the reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence. For example, for repeated incision and drainage of an abscessed paronychia, the medical record should document any additional measures taken to prevent reoccurrence and/or the reason for not performing more definitive treatment (e.g., the patient refuses and/or is not a candidate for permanent, partial or complete nail and nail matrix removal).
