Cracking the Code
Incisions and Drainage
A lot of incision and drainage procedures involve draining areas of the skin and subcutaneous tissues; however, there are some cases where the surgeon goes deeper into the fascia, muscle, bone, joint, or internal organ. When reviewing the operative report, it is important to understand the intent of the procedure, how many procedures are being completed, the depth of the procedure, and the type of device that is being used during the treatment.
Q: A patient presents with right neck swelling, redness, and drainage. The surgeon confirms that the patient has a neck abscess and decides to perform an incision and drainage procedure to treat the abscess. A skin incision in the right neck is completed. There is purulent drainage followed by blunt dissection until the cavity was visualized. At the completion of surgery, a Penrose drain was placed and secured. The patient tolerated the procedure well and is discharged home.
A: 0J940ZZ, drainage of right neck subcutaneous tissue and fascia, open approach 10060, incision and drainage of abscess; simple or single
Reference: ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021 B6.1b and AHA Coding Clinic Third Quarter 2018 pages 16-17: Incision and drainage of neck abscess