A patient underwent an incision and drainage procedure at our facility. According to the operative report, an incision was made over the lesion and purulent material was expressed. Loculations were broken up using forceps and more of the material was expressed. The drainage cavity was then irrigated, packed and dressed with sterile gauze.

Would it be appropriate to code an incision and drainage (I&D) as complicated based on documentation that a drain or packing was used? There are many articles available that provide varying opinions and we would appreciate an official response. Should the term complicated be documented or may the coder use the drain or packing as an indicator of a complicated procedure?

ANSWER

No, it would be inappropriate for the coder to assume that the incision and drainage is complicated based on the use of a drain or packing without confirmation from the physician. When the documentation is unclear the coder should query the physician for clarification.

With that said my question is- If I’m not basing a complex I&D on whether the provider used packing or a drain, can use the fact that they probed for loculations, or explored the abscess further to come to a 10061(complex; multiple) for a more complex procedure? I’m asking in the absence of a query would probing and/or breaking up loculations be evidence of a complex I&D? According to the coding clinic we just can’t assume placement of a wick or drain is evidence of the complexity but it says nothing about probing, or breaking anything up shouldn’t be used to determine the complexity. I know it’s at the discretion of the provider, but unless they state it was complex OR if there was more than one abscess then what other indication is there to code a 10061 for the (complicated;multiple except for the obvious more than one)?
Do we call everything a simple I&D unless the provider states it’s complex?

Thank you!