By Azure’re Heatley, CPC, Maxim Healthcare Staffing
What is a skin abscess and proper code for the site?
A skin abscess, also called a boil, is a bump that appears within or below the skin’s surface. This bump is usually full of pus or translucent fluid. It’s typically due to a bacterial infection.
When abstracting an abscess from documentation, most often for skin abscess, you need to identify the site for coding.
When the abscess is caused by bacteria, the organism (B95-B97) needs to be abstracted per the additional note prompted in the ICD-10 CM code book.
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How to treat a skin abscess?
Home treatment options
You can usually treat a skin abscess at home. Applying heat to the abscess can help it shrink and drain.
The most useful way of applying heat is to put a warm compress on the abscess. You can make a warm compress by running warm water on a face towel and folding it before placing it on the abscess.
Drainage
See your doctor if the abscess is stubborn and doesn’t heal using home methods. They may want to drain it.
To drain the abscess, your doctor will apply numbing medications and will then cut the abscess open to allow the fluid to come out. After the abscess drains, your doctor will pack the wound with surgical material. This helps it to heal and prevents the abscess from recurring.
When abstracting the procedure code for an Incision and Drainage (I&D) of an abscess, it is extremely important to pay close attention to the terminology used and documentation of the said procedure. When the physician is utilizing a scalpel to puncture the area and drain the innards of the abscess, the procedure used should be a simple I&D (CPT 10060). When the physician states that loculations were decompressed or the abscess sac was removed completely, the procedure used should be complex (CPT 10061).
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