L29194-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Incision and Drainage of Abscess of

Skin, Subcutaneous and Accessory Structures (L29194)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29194

LCD Title

Primary Geographic Jurisdiction opens in new window

Incision and Drainage of Abscess of Skin, Subcutaneous Florida and Accessory Structures

Contractor's Determination Number 10060

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

N/A

Indications and Limitations of Coverage and/or Medical Necessity

An abscess is a cavity containing pus surrounded by inflamed tissue. It is generally associated with pain, swelling and erythema. An abscess often requires incision and drainage to remove the purulent material in order for healing to occur.

Procedure codes 10060 and 10061 represent incision and drainage of an abscess involving the skin, subcutaneous and/or accessory structures. This includes the following types of abscess: furuncle, carbuncle, suppurative hidradenitis, an abscessed cyst, an abscessed paronychia, and/or other abscess involving the cutaneous and/or subcutaneous structures.

Medicare will consider the use of incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures to be medically reasonable and necessary for the treatment of a symptomatic abscess (e.g. inflamed, painful, tender) involving these structures. This includes the incision and drainage of the following types of abscess:

furuncle; carbuncle;

suppurative hidradenitis; an abscessed cyst;

an abscessed paronychia; and/or other abscess of cutaneous and/or subcutaneous structures.

It would not generally be expected to see incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures to be repeated frequently and/or multiple times. If frequent repeated incision and drainage is required, the medical record must reflect the reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE

10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE

ICD-9 Codes that Support Medical Necessity

528.5 DISEASES OF LIPS

607.2 OTHER INFLAMMATORY DISORDERS OF PENIS

611.0 INFLAMMATORY DISEASE OF BREAST

680.0 - 680.9 CARBUNCLE AND FURUNCLE OF FACE - CARBUNCLE AND FURUNCLE OF UNSPECIFIED SITE

681.02 ONYCHIA AND PARONYCHIA OF FINGER

681.10 - 681.11

682.0 - 682.9UNSPECIFIED CELLULITIS AND ABSCESS OF TOE - ONYCHIA AND PARONYCHIA OF TOE CELLULITIS AND ABSCESS OF FACE - CELLULITIS AND ABSCESS OF UNSPECIFIED SITES

705.83 HIDRADENITIS

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the service being billed. As stated in the "Coding Guidelines" section, the medical record must clearly indicate that an abscess was present. This should include the location, size, and appearance of the abscess.

In addition, documentation that the service was performed (incision and drainage of purulent material from an abscess) must be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

Furthermore, the medical record must clearly document the medical necessity for repeated incision and drainage of an abscess. If frequent incision and drainage is required, the medical record must reflect the reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence. For example, for repeated incision and drainage of an abscessed paronychia, the medical record should document any additional measures taken to prevent reoccurrence and/or the reason for not performing more definitive treatment (e.g.,

the patient refuses and/or is not a candidate for permanent, partial or complete nail and nail matrix removal).

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Marx, J; Hockberger, R; Wakks, R. (2002). Rosen’s Emergency Medicine, Concepts and Clinical Practice, 5th edition. Pages 1949-1953, Mosby’s, Inc.

Richards, T. Skin or Soft Tissue Abscess. McKesson Health Solutions LLC. (2004).

Roberts, J; Hedges, J (2004). Clinical Procedures in Emergency Medicine, 4th ed. Pages 718-746, Elsevier, Inc. Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29194) replaces LCD L5423 as the policy in notice. This document (L29194) is effective on 02/02/2009.

Reason for Change