Coding for I&D, DTaP, and Procedures Included in the E/M Code

Q. An urgent care that I do billing for has presented a question I would like your input on. A sales rep has stated that urgent care centers are now administering DTaP in urgent care, and, if so, what is the difference between the reimbursement of the Td (90714) and the DTaP (90715)?

Lynn Gray, Eastern Hills Medical Billing, Cincinnati, OH
A. Patients may use urgent care centers when they have difficulty getting timely appointment for an immunization with a primary care physician. In general, place of service should not change whether it is appropriate or not to administer the vaccine. Any payor, however, may choose to deny a code, based on a contract with the provider or individual payor policies.
When it comes to actual reimbursement, fee schedules are set by payors, so you will need to check with each payor to determine the fee schedule rate for each code. Of course, the code that you use should not be based on reimbursement levels; rather, the code should correlate with the specific service that has been provided.

Q. What is the best code to use when we do not repair a laceration and are just cleaning a scrape or contusion?

Misha Doctor, Nason Medical Center, Charleston, SC

Q. CPT and CMS consider cleansing a wound to be a minor procedure that is not separately reported with a CPT or HCPCS code. It is included in the E/M service, and performing this service does not alter the algorithm for calculating the E/M code.

A. When one of our providers places an ear wick, they write in the code 69399. I’ve looked it the 2009 CPT code book, and this code is listed under reconstruction auditory canal and is an unlisted procedure, external ear. Do you know if there is another code that we should use for an ear wick?
Adam Walker, Physicians Care, Chattanooga, TN

Q. Again, CPT and CMS consider insertion and/or removal of an ear wick(s) as a minor procedure that is not separately reported with a CPT and HCPCS code. Ear wick insertion is included in the E/M service, and performing this service does not alter the algorithm for calculating the E/M code.

A. How do we code for multiple visits for repeat procedures – for example, when a patient makes several daily clinic visits for removal of packing and repacking of the abscess after an incision an drainage (I&D) of the abscess?
Scott Cooney, Bellevue Urgent Care, Greater Omaha Area, NE

1. Every procedure code has an associated global period. This global period includes much of the follow-up care during that global period. Examples of procedures and their associated global periods include:

• 96372: IM injection, 0-day global period
• 12001: Simple laceration repair, 10-day global period
• 26720: Fracture finger (when definitive care is performed), 90-day global period

In the case that you describe, would packing and repacking during the global period for the I&D would be included in the global package. If course, in some cases the patient does require multiple visits during the global period. Each of these visits would be coded with code 99058, which has no associated reimbursement.
In the case of fractures, however, some follow-up care (i.e., x-rays, cast supplies, and cast reapplications and modifications) is not included in the global care. This even applies to the global period for definitive fracture care. You may code for these services and supplies in addition to the procedure code for fracture care.

Q. What procedure code would I use on incision and drainage of a large (8 cm) skin abscess near the medial right periscapular border? It required probably three times more supplies and time than a usual skin abscess. It was, however, superficial to all muscles. The 20000 code wouldn’t seem to reimburse enough.

Alan L. Carpenter, DO, Upper Valley Urgent Care Center, El Paso, TX
A. There is one code specific to the body area that might apply here: 21501 – Incision and drainage, deep abscess or hematoma, soft tissue of neck or thorax.
With several other codes for “deep incision and drainage,” CPT is specific in defining “deep” as “subfascial.” With this code, however, CPT and CPT Assistant are silent on the definition of “deep.” Thus, you should use your clinical judgement to determine whether the abscess would fit the definition of “deep,”
There are two general codes for I&D of an abscess:

• 10060 – Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
• 10061 – Incision and drainage of abscess (e.g., carbuncle, suppurative, hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple
• The second code, 10061, is probably the best code to use for the procedure you describe. Make sure that your procedure note makes it clear that this was a complicated procedure.

Note: There are also codes for I&D of abscesses (or hematomas) in some specific situations or of anatomic locations (Table 1). Because these codes most accurately describe the procedure performed, you should use these codes when they apply.