Local Coverage Article Billing and Coding

Billing and Coding: Incision and Drainage of Abscess of Skin, Subcutaneous and Accessory Structures

A57783

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Contractor Information

Article Information

General Information

Article ID
A57783
Article Title
Billing and Coding: Incision and Drainage of Abscess of Skin, Subcutaneous and Accessory Structures
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
10/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
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  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

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

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. 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.
  3. 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.
  4. The medical record must clearly indicate that an abscess was present. This should include the location, size, and appearance of the abscess. 
  5. 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). 

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
10060 Drainage of skin abscess
10061 Drainage of skin abscess

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(101 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 10060 and 10061.

Group 1 Codes
CodeDescription
K13.0 Diseases of lips
L02.01 Cutaneous abscess of face
L02.02 Furuncle of face
L02.03 Carbuncle of face
L02.11 Cutaneous abscess of neck
L02.12 Furuncle of neck
L02.13 Carbuncle of neck
L02.211 Cutaneous abscess of abdominal wall
L02.212 Cutaneous abscess of back [any part, except buttock]
L02.213 Cutaneous abscess of chest wall
L02.214 Cutaneous abscess of groin
L02.215 Cutaneous abscess of perineum
L02.216 Cutaneous abscess of umbilicus
L02.221 Furuncle of abdominal wall
L02.222 Furuncle of back [any part, except buttock]
L02.223 Furuncle of chest wall
L02.224 Furuncle of groin
L02.225 Furuncle of perineum
L02.226 Furuncle of umbilicus
L02.231 Carbuncle of abdominal wall
L02.232 Carbuncle of back [any part, except buttock]
L02.233 Carbuncle of chest wall
L02.234 Carbuncle of groin
L02.235 Carbuncle of perineum
L02.236 Carbuncle of umbilicus
L02.31 Cutaneous abscess of buttock
L02.32 Furuncle of buttock
L02.33 Carbuncle of buttock
L02.411 Cutaneous abscess of right axilla
L02.412 Cutaneous abscess of left axilla
L02.413 Cutaneous abscess of right upper limb
L02.414 Cutaneous abscess of left upper limb
L02.415 Cutaneous abscess of right lower limb
L02.416 Cutaneous abscess of left lower limb
L02.421 Furuncle of right axilla
L02.422 Furuncle of left axilla
L02.423 Furuncle of right upper limb
L02.424 Furuncle of left upper limb
L02.425 Furuncle of right lower limb
L02.426 Furuncle of left lower limb
L02.431 Carbuncle of right axilla
L02.432 Carbuncle of left axilla
L02.433 Carbuncle of right upper limb
L02.434 Carbuncle of left upper limb
L02.435 Carbuncle of right lower limb
L02.436 Carbuncle of left lower limb
L02.511 Cutaneous abscess of right hand
L02.512 Cutaneous abscess of left hand
L02.521 Furuncle right hand
L02.522 Furuncle left hand
L02.531 Carbuncle of right hand
L02.532 Carbuncle of left hand
L02.611 Cutaneous abscess of right foot
L02.612 Cutaneous abscess of left foot
L02.619 Cutaneous abscess of unspecified foot
L02.621 Furuncle of right foot
L02.622 Furuncle of left foot
L02.631 Carbuncle of right foot
L02.632 Carbuncle of left foot
L02.811 Cutaneous abscess of head [any part, except face]
L02.818 Cutaneous abscess of other sites
L02.821 Furuncle of head [any part, except face]
L02.828 Furuncle of other sites
L02.831 Carbuncle of head [any part, except face]
L02.838 Carbuncle of other sites
L02.91 Cutaneous abscess, unspecified
L02.92 Furuncle, unspecified
L02.93 Carbuncle, unspecified
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.019 Cellulitis of unspecified finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.039 Cellulitis of unspecified toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L03.818 Cellulitis of other sites
L03.90 Cellulitis, unspecified
L73.2 Hidradenitis suppurativa
N48.21 Abscess of corpus cavernosum and penis
N48.22 Cellulitis of corpus cavernosum and penis
N48.29 Other inflammatory disorders of penis
N61.0 Mastitis without abscess
N61.1 Abscess of the breast and nipple
N61.21 Granulomatous mastitis, right breast
N61.22 Granulomatous mastitis, left breast
N61.23 Granulomatous mastitis, bilateral breast

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

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
CodeDescription
XX000 Not Applicable

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
999x Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2020 R1

Revision Number: 1
Publication: September 2020 Connection
LCR B2020-013

Explanation of revision: Based on CR 11845 (Annual 2021 ICD-10-CM Update), the “ICD-10 Codes that Support Medical Necessity/ Group 1 Codes:” section of this billing and coding article was revised to add ICD-10-CM code N61.21, N61.22 and N61.23. In addition, formatting changes have been made throughout the article. The effective date of this revision is based on date of service.

Associated Documents

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