URGENT MESSAGE: Laceration repairs and abscess drainage are two of the most commonly performed procedures in urgent care. Correct coding entails understanding what components are bundled with the surgical procedure, documentation of the diagnosis, location and size of the laceration or abscess, and the surgical technique utilized.
Sarah Todt, RN, CPC, CEDC, CPMA is Director of Provider Education at LogixHealth. Deborah A. Wilson, RN, CPC, CEDC is Associate Director of Provider Education at LogixHealth.
Care provided in the urgent care setting stretches well beyond evaluation and management. For example, integumentary system procedures, whether needed due to a medical condition or injury, are among the most common performed in urgent care centers. In order to be reimbursed properly, operators must ensure that the description of the condition, as well as the procedure technique employed, are reported accurately.
Bundled Guidelines for Surgical Procedures
When a procedural code is reported, it is necessary to understand what is included in the surgical package. The CPT® instructions for surgical procedures list components that are considered bundled and may not be reported separately. These include local anesthesia, including digital block, as well as immediate postoperative care and typical post-op follow-up care. The instructions also allow for an evaluation and management service “subsequent to the decision for surgery.” An evaluation and management service may be appropriate, in addition to the surgical procedure in the urgent care setting, when medical necessity is met.
Incision and Drainage
Skin infections are a common complaint in the urgent care and primary care settings. When these infections develop into an abscess—a collection of pus from a localized skin and subcutaneous tissue infection that can result in tissue destruction—the provider may have to perform an incision and drainage. Patients may present with a minor abscess, multiple abscesses, or complex abscesses.
The treatment for abscesses can vary, depending on the location and severity of the infection. Treatments modalities include simple puncture, an incision with irrigation, breaking up of loculations and packing, or drain placement. The proper code assignment depends on the location and technique. Providers should be aware of the procedure code descriptions to ensure that documentation of the procedure allows for accurate capture of the service. As always, the final diagnosis should contain specificity to reflect the condition.
For smaller abscesses, the physician may simply aspirate the fluid with a syringe and needle; this would be accurately represented by CPT code 10160, Puncture aspiration of abscess, hematoma, bulla, or cyst.
Larger and complicated abscesses will require more invasive treatments. Incision and drainage of subcutaneous tissues may be reported as either “simple” or “complicated” procedures. Simple procedures would be reported with CPT 10060, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single. These procedures include local anesthetic and a simple incision of a single abscess.
When multiple abscesses are treated, or if there is a more complicated procedure, the service would be reported with CPT 10061, Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. These procedures often involve larger abscesses that require irrigation and/or probing to break up loculations and packing or drain placement to promote ongoing drainage.
There are additional incision and drainage codes available based on other anatomic locations involved. For example, incision and drainage of a pilonidal abscess (a collection of pus that appears like a large pimple in the center of the back, just above the buttocks) may be reported as simple or complicated. CPT 10080, Incision and drainage of pilonidal cyst; simple represents the most typical treatment reported.
The complicated procedure, 10081, Incision and drainage of pilonidal cyst; complicated, has some specific requirements of treatment including marsupialization, approximation of the wounds edges, and/or primary closure; however, this is not typically reported in the urgent care setting.
The record should always clearly illustrate the procedure performed, and any complications, to ensure proper code assignment.
Assignment of the appropriate code for an incision and drainage of a finger may be a challenge even to a seasoned coder. Incision and drainage of abscesses of the finger which involve the lateral aspect of the nail are reported with the subcutaneous tissue incision and drainage codes as described above. When the abscess involves the deeper structure, such as the fat pad of the finger, a different service is represented. CPT code 26010, Drainage of finger abscess; simple represents this type of procedure. CPT code 26011, Drainage of finger abscess; complicated (eg, felon) should be reported with more complicated abscesses or a felon, which require debridement or irrigation for treatment.
Integumentary Procedures for Injuries
Lacerations are also among the most common injuries that require a procedure in the urgent care setting. There are multiple procedure codes for laceration repairs based on location, size, and technique. Detailed documentation of the wound and the repair are necessary to determine the appropriate repair code.
Laceration repairs are divided into three categories: simple, intermediate, and complex (as explained further under Laceration Repairs, below); those categories are further divided by length and by anatomical groupings. The CPT book gives clear instruction on how to apply these codes.
Laceration Repairs
The first laceration repair type is simple wound repair, which refers to wounds that require only a single layer closure of the epidermis or dermis. Deeper structures are not involved. Closure is achieved either by suture material or by chemical closure with tissue adhesive.
Wounds requiring multilayer subcutaneous tissue and nonmuscle fascia closure, in addition to the epidermis or dermis closure, are reported as intermediate repair. Heavily contaminated wounds requiring extensive cleaning or particulate debris removal and single- layer closure also represent intermediate repairs.
A complex repair requires additional work beyond an intermediate repair and typically includes scar revision, undermining, or placement of stents or retention sutures. Complex repairs may also include defect creation for repair. A physician may describe wound repair as complex when in fact the procedure only meets simple or intermediate repair. The technique employed should clearly be documented.
CPT assignment for multiple laceration repairs is determined by both complexity and anatomic location. Multiple lacerations of the same type and same anatomic location are reported with a single repair code. The lengths of the lacerations are added together to determine the length and appropriate code. Multiple lacerations with different complexities or different anatomic locations are reported with separate codes.
Open wound (laceration) repair often involves simple blood vessels ligations, or may require simple exploration to evaluate blood vessels, nerves, or tendons. These activities are considered inherent to the procedure and are not separately reportable.
Providers should be aware of procedures that may be reported and understand the important elements to be documented. In order to report a surgical procedure, the provider must clearly document the extent and scope of the service provided. Clear documentation will allow for good communication and appropriate valuation services.