Drain, pare, snip

By Alexander Miller, MD, December 1, 2019

The Surgery, Integumentary System section of the CPT^® manual presents a variety of incision and drainage, paring and curetting, and skin tag removal codes. Selecting an appropriate code can be challenging.

Incision and drainage CPT definitions include the below codes most pertinent to dermatology:

• 10040 Acne surgery (e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)

• 10060 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

• 10061 complicated or multiple

• 10120 Incision and removal of foreign body, subcutaneous tissues; simple

• 10121 complicated

• 10140 Incision and drainage of hematoma, seroma, or fluid collection

Code 10040 includes puncturing/opening and removal of milia, which are not acne lesions. However, “cysts” are also included.

What is different between the “cysts” in code 10040 and those specified in 10060? Although CPT does not specifically tackle this distinction, it is apparent that 10040 is principally designed for reporting acne surgery, including the opening or removal of acne cysts.

When does an acne “cyst” become an “abscess” subject to reporting code 10060 when drained? This is not clarified in CPT or CPT Assistant. Similarly, at which point does an incision and drainage of an abscess, including that of an abscessed epidermal inclusion cyst, become complicated? Neither CPT nor CPT Assistant provide precise guidance.

CPT Assistant provided the following comment to an inquiry: “Many of the incision and drainage codes (i.e., 10060-10140, 10180) include one code for simple procedures and one code for complicated procedures. Does the CPT code set define these terms?

"The choice of code is at the physician's discretion, based on the level of difficulty involved in the incision and drainage procedure” (Dec. 2006, page 5).

One may surmise that incising and draining alone would be simple, whereas incising, then draining, and mechanically cleaning out the abscess cavity, and/or packing it, or placing a drain would qualify as complex.

Paring or cutting are defined by CPT as:

• 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion

• 11056 2 to 4 lesions

• 11057 more than 4 lesions

One is to report only one of the above codes per treatment session. For example, if three hyperkeratotic lesions were pared, one would code CPT 11056 only, rather than 11055 plus 11056.

CPT specifies removal of skin tags as: “Removal by scissoring or any sharp method, ligature strangulation, electrosurgical destruction, or combination of treatment modalities, including chemical destruction or electrocauterization of wound, with or without local anesthesia.”

• 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

• +11201 each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure)

The above codes include just about any modality for ridding a patient of skin tags except for laser destruction. Benign lesion destruction, CPT 17110 and 17111, includes destruction by laser. However, CPT prohibits the use of these codes for skin tag removal. If for some reason one were driven to destroy skin tags with laser, one would have to report CPT code 17999, “Unlisted procedure, skin, mucous membrane and subcutaneous tissue.”

Example 1: A patient seeks relief from a tender, painful to walk on punctate keratosis on the plantar foot. You vigorously pare down the punctate keratosis, resulting in total pain relief. Great. Now how do you report this service? After considering that the CPT definition of paring/cutting includes, “(e.g., corn or callus)” you infer that code 11055, “paring or cutting of benign hyperkeratotic lesion,” would pertain to other hyperkeratoses, and you report CPT 11055.

Answer: Correct. CPT Assistant, January 1999, page 11, clarifies: “The use of the codes 11055-11057 is not restricted to the examples given in parentheses as part of the code descriptor.” CPT Assistant, September 2010, page 9, further confirms this interpretation.

Example 2: A fusiform excision on the cheek measures maximally as 1.5 cm perpendicular to the layered repair’s line of closure. Undermining is done along both entire edges of the fusiform defect, 1.0 cm on one side and 0.5 cm on the opposite side. The combined distance of undermining equals the maximum defect width, 1.5 cm. Consequently, a complex repair code is reported.

Answer: Incorrect. Chapter One of the National Correct Coding Initiative (NCCI) guidance states that when multiple approaches are utilized to achieve the same outcome, one can only report the most extensive procedure, the one likely to achieve the intended outcome, which is the more definitive cryodestruction. In this case, only CPT 17110 should be reported.

Example 3: You snip off 10 large axillary skin tags and separately electrofulgurate 12 small neck skin tags. You report CPT 11200 for the snips and 17110 for the electrodestruction of the neck tags.

Answer: Incorrect. Although two distinct removal procedures were used, only one CPT code series is appropriate. Codes 11200 and 11201 include skin tag removal by “any sharp method, ligature strangulation, electrosurgical destruction, or combination of treatment modalities, including chemical destruction…with or without local anesthesia” (CPT 2020). Since 22 tags are treated, one should code 11200 for the first 15 tags and 11201 for the remaining seven.

Example 4: A patient has a cactus splinter that has penetrated subdermally and then broken off at the surface. You remove it with an incision, instrumentation, and exploration of the dermis to expose the splinter, which is found within the dermis and subcutaneous space, and then extracted. Should you report CPT 10120 or 10121 for the incision and removal of the foreign body, or CPT 28190, “Removal of foreign body, foot; subcutaneous”? You select CPT 10121.

Answer: Correct. Codes 10120 and 10121 refer to foreign bodies lodged within the skin and subcutaneous fat. The 28190 to 28193 code series pertains to foreign bodies that have penetrated into the fascia, subfascial space, or muscle. One should therefore document the depth of foreign body penetration in order to justify the 28190-28193 code selection (CPT Assistant, December 2013, page 16). CPT 10121 is reported since the removal of the splinter required more than simple incision and direct extraction of the splinter.

Example 5: You incise and drain clear, slippery, somewhat gelatinous material from a distal finger digital mucous cyst. You report CPT 10140, Incision and drainage of hematoma, seroma, or fluid collection.

Answer: Partially correct. No code specifically dedicated to I&D of digital mucous cysts exists. One must choose from two distinct codes, 10140, which includes I&D of a “fluid collection” and 10060, which incorporates I&D of an abscess and cyst. A digital mucous cyst drains a type of fluid, but it is referred to as a cyst. In this case it seems that either codes 10140 or 10060 can describe the procedure.

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