The diagnostic code you use needs to be identical to that used by the surgeon. The date of service should correspond to the date of the surgery. Use the same surgical CPT procedure code used by the surgeon, but add the -55 modifier to signify that you are rendering the postoperative care.
Postoperative care is the care you receive after a surgical procedure. The type of postoperative care you need depends on the type of surgery you have, as well as your health history.
Postprocedural retroperitoneal abscess The 2022 edition of ICD-10-CM K68. 11 became effective on October 1, 2021.
Infection following a procedure, other surgical site The 2022 edition of ICD-10-CM T81. 49 became effective on October 1, 2021. This is the American ICD-10-CM version of T81. 49 - other international versions of ICD-10 T81.
Postoperative wound infection is classified to ICD-9-CM code 998.59, Other postoperative infection. Code 998.59 also includes postoperative intra-abdominal abscess, postoperative stitch abscess, postoperative subphrenic abscess, postoperative wound abscess, and postoperative septicemia.
10061 Incision and drainage of abscess; complicated or multiple.
Encounter for other specified surgical aftercare Z48. 89 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z48. 89 became effective on October 1, 2021.
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Procedure codes 10060 and 10061 represent incision and drainage of an abscess involving the skin, subcutaneous and/or accessory structures.
Z48. 0 - Encounter for attention to dressings, sutures and drains. ICD-10-CM.
A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only.
Abscesses. The first code in the CPT series for incision and drainage, CPT 10060-10061, defines the procedure as “incision and drainage of abscess (carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single and complex or multiple.”
CPT code 10080 is used for a simple incision and drainage with local wound care to facilitate healing. And CPT code 10081 for a complicated incision and drainage which includes placement of a drain or packing with gauze. For percutaneous aspiration of abscess, hematoma, bulla or cyst, procedure code 10160 is used.
A complex I&D is generally defined as an abscess requiring placement of a drainage tube, allowing continuous drainage, or packing to facilitate healing. As a physician, it is important that you document precisely, notating the simplicity or complexity of the procedure, as well as how deep the incision(s) is.