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DAVID STERN, MD (Practice Velocity)

Q.We have so many MRSA (methicillin-resistant Staphylococcus aureus) I&Ds (incision and drainage). The follow-up for changing the packing are numerous and time-consuming, and it feels wrong to have them just included in the global procedure like any other wound check or suture removal. What’s the right way to handle this?

Annie Miranda, Hopewell Junction, NY

A. This is a complicated question. To code these procedures, you can consider using the code for a complicated I&D (10061: incision and drainage of abscess – complicated or multiple). If the incision and drainage (I&D) procedure involves placing a drain or packing, many coders will consider this procedure “complicated.” Neither the Centers for Medicare & Medicaid Services (CMS) not the American Medical Association (AMA) has given specific guidance as to what constitutes “complicated,” so this definition is left up to the payor and physician. Many coders believe that this definition of “complicated” is appropriate because the procedure requires a follow-up visit for packing removal and because the abscess often requires replacement of the packing or drain.

This code does carry a 10-day global period. That mean that all routine follow-up care (including repacking the abscess) is included in the code. For Medicare patients, all care (including complications) is included in the global package for the initial code. However, AMA defines the global period for CPT codes as only applying to routine follow-up care. Thus, many coders will bill an E/M code for follow-up visits that involve complications, even if the visit occurs during the global period for the initial procedure.

There are other options for accurately coding some incision and drainage procedures that may also compensate your practice for large amount of work required for these cases:

  • Additional I&D: If, no recheck, the abscess requires additional incision and drainage, then you could again code 10060 and use modifier -76 (repeat procedure or service by same physician) for the claim with the repeat I&D. Make sure that the physician documents that the abscess requires more drainage. Some payors restricted use of modifier -76 to a repeat procedure performed on the same day as the original procedure. However, this was clarified in the AMA’s CPT Changes 2008: An Insider’s View: “Use of modifier 76 is not restricted to procedures performed on the same day. The repeated service could be surgical or diagnostic, but cannot be an evaluation and management (E&M) service.” Not that “both services – the original and the repeat – must be described by the exact same CPT code.” (CPT Changes 2011: An Insider’s View)
  • Regional I&D codes for deep abscesses or hematomas: If the abscess is “deep,” then the provider can use a specific code to code for the procedure. Neither CMS nor AMA has specified what the definition of “deep” is, but the procedure note should clearly indicate the appropriate body area and “deep” tissue layer that was dissected for the I&D. These codes are defined by body area and include for extremities:
    • Upper Arm/Elbow: 23930
    • Forearm/Wrist: 25028
    • Thigh/Knee: 27301
    • Leg/Ankle: 27603

Q. Why won’t some major payors pay for POS code 20 (services rendered at an urgent care facility) for R-codes?

Myrtle Brooks, Orlando, FL
A. If you are referring to R HCPCS codes, R-codes would probably not apply to POS 20. By definition they occur outside of an urgent care clinic. In addition, these are services that are almost never rendered by an urgent care center. R HCPCS codes are:

  • R0070: Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.
  • R0075: Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen.
  • R0076: Transportation of portable EKG to facility or location, per patient.

Q. Code A4460 (elastic/compression bandage used with lymphatic drainage) was deleted in 2003. In urgent care, what code would I use for a compression bandage given to a patient for foot pain or wrist pain?

Name withheld
A. You would use on of the following codes:

  • A6448: Light compression bandage, elastic, knitted/woven, width less than 3 inches, per yard.
  • A6449: Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 inches and less than 5 inches, per yard.
  • A6450: Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 inches, per yard.

Note: CPT codes, descriptions, and other data only are copyright 2011, American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.

Coding for I&D Follow-Up, R-codes and POS 20, Coding for Compression Bandage

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine