CMS Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures Form

Summary Of Evidence

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Analysis of Evidence

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Abstract:

This local coverage determination (LCD) specifies the indications and limitations for incision and drainage services. Incision and drainage is a covered procedure for treating abscesses. Incision and drainage of non-abscess fluid collections is covered when medically necessary due to pain or inflammation. Repeated incision and drainage is not expected, however, in the case of hidradenitis, this may be experienced but the provider must document the reason that more definitive therapy is not appropriate.

Podiatrists are limited in scope of practice by State law. Only those ICD-10-CM codes that are appropriate for the scope of practice will be accepted as reimbursable.

The patient's medical record must contain documentation that fully supports the medical necessity for the incision and drainage as well as a full description of the procedure performed.

Indications:

Incision and drainage or puncture aspiration describes the mechanical task of introducing a sharp sterile instrument into a discrete subcutaneous collection of pus, blood or other fluid for the purpose of removing from the lesion said pus, bacteria, blood, necrotic tissue, or other toxins, to promote resolution of infection, inflammation, and pain or to obtain material for diagnostic analysis.

An abscess is a circumscribed collection of pus of any size in any location, and as such represents an infection. Abscesses usually exhibit one or more of the following clinical findings: redness, warmth, tenderness, fluctuance, edema, lymphangitis. A lesion not exhibiting such signs or symptoms and that does not contain pus or infected purulent fluid is not an abscess, but may be some other type of process requiring incision and drainage such as a hematoma, seroma, bulla or cyst. A simple abscess generally requires only a single puncture or single incision. A complicated abscess with infection and necrosis usually requires more effort to treat. Examples of complicated abscesses are the following: an abscess with 3-4 tracks requiring breaking up of loculated compartments; an abscess requiring undermining of the skin and subcutaneous tissue and extensive laying open of the cavity. In these circumstances, at minimum, locally injected anesthesia is usually required.

Incision and drainage services are covered for treating abscesses (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, post-operative wound infections, or paronychia). Incision and drainage of hematomas, seromas, cysts or other pathologic fluid collections are covered when medically necessary due to pain, inflammation or infection.

Paronychia is an acute or chronic inflammation of the periungual tissues, which may be associated with infection, purulence and granulation tissue. Acute paronychia is treated by relieving pressure on the soft tissues either by packing or by removing a section of nail plate and packing. This usually allows for sufficient drainage to avoid the need for incision and drainage of the soft tissues. This technique is used in the foot with some modifications including the removal of larger sections of nail plate and correction of pathomechanical foot function. However, this technique does not involve the direct incision and drainage of a discrete soft tissue pus or fluid collection and should not be billed as an incision and drainage service. 

Limitations:

Incision and drainage of an abscess is limited to lesions with documented abscess and/or pus collection and is not appropriate for treatment of blisters, cysts (including sebaceous cyst), or other fluid collections without the documented presence of discrete abscess, pus collection, pain, infection or inflammation.

If there is inflammation adjacent to a nail or ingrown nail and the only service provided is trimming the edge of the nail, the incision and drainage codes should not be used. Trimming the nail to prevent recurrence of paronychia is considered to be routine foot care, which has limited coverage.

Incision and drainage services are not payable for treatment of blisters unless there is superinfection with pus and abscess formation.

Providers performing permanent correction of recurring ingrown nail by nail resection (plate, bed, and nail matrix, partial or complete) or by wedge excision of the nail lip, should not bill incision and drainage services. Removal of lytic fragments of the nail plate to relieve symptoms of inflammation without infection of the soft tissues is a routine foot care procedure.