A 2 cm incision was made transversely across the apex of the abscess. The resulting purulent material was cultured. The the cavity was opened widely with a hemostat with expression of approximately 3 mL's of dark. Material. The cavity was then packed with 1/4 inch iodoform gauze. Cover dressing was then applied.
Provider used dx for Perianal abscess and Perianal cyst. He coded cpt 20005 though I am thinking it should be 10060. Which code would be correct?
What was the reason for the incision… the Cyst (it was an abscessed Perianal cyst ).
20005 is used to report incision and drainage of soft tissue, and may involve deep fascia. This code is used for an abscess only.
10060 is used for an I&D of abscess such as a carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia. This code should be used if the procedure was simple or a single abscess.
The note mentioned the cavity was packed, a drain or a pack would be considered complex. (complicated abscesses require placement of drain or packing.) Due to the fact this incision required packing you would consider 10061-Complicated.