Incision and Drainage FAQ

The CPT/ICD-10 codes for incision and drainage procedures vary based on factors such as the location, depth, and type of lesion, the presence of complicating factors, multiple lesions, and whether the procedure was simple or complicated.

For accurate coding, the medical record should include the signs/symptoms exhibited by the patient that necessitated the need for an I&D procedure. Additionally, details of the wound, such as pre-procedure size, precise location, and type of lesion (e.g., abscess, paronychia, hidradenitis suppurativa, furuncle, carbuncle, lymphangitis, hematoma, cyst) should be reflected in the ED chart. The procedure note should include details of the procedure, including incision or puncture, amount and quality of drainage, probing and deloculation when performed, and whether the wound was packed, drain inserted, vessel loop placed or left open.

Use care when choosing the correct CPT codes. Some descriptors indicate incision or puncture, while others do not specify the type of approach for a specific location. Similarly, ICD-10-CM diagnosis codes linked to the procedure should accurately reflect the location and type of lesion drained.

Complexity of an I&D is determined by the provider. Generally, a complicated I&D may include wound packing, drain insertion, and/or probing and deloculation. Multiple skin or subcutaneous I&D during the same encounter are coded as complicated, rather than coding multiple simple I&D, per CPT.

Ultrasound interpretation is a separately billable service frequently used to diagnose and locate a cyst, hematoma, seroma or abscess. Permanent image retention and documented findings related to the reason the study was performed are necessary to capture ultrasound as a separately billable service.  There are ultrasound codes available specifically for soft tissue of the head and neck (CPT 76536) and soft tissue of non-vascular extremity structure (CPT 76882). Additional ultrasound codes are assigned by body area, including abdomen (CPT 76705) or chest/upper back (CPT 76604), and scrotum contents (CPT 76870). Use the -26 modifier to indicate professional component interpretation. If an ultrasound code description does not indicate limited study, a -52 reduced service modifier may be appropriate.   

For additional information, see the ACEP FAQ for Ultrasounds.

The following list provides some examples of incision and drainage as well as puncture aspiration codes frequently performed in the emergency department: 

Most incision and drainage or puncture aspiration codes utilized in the emergency department carry a ten (10) day global period. Routine follow-up visits to the same ED, seen by the same provider/group, and limited to re-evaluation of the uncomplicated post-procedural wound may be captured with CPT® 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure). 

If the patient presents during the 10-day global period with additional medical problems or conditions unrelated to the incision and drainage or puncture aspiration (e.g., diabetes or URI), an Evaluation/Management Level may be billed with a -24 modifier to indicate an unrelated E/M service by the same physician or other qualified health care professional during a postoperative period.