LCD Information. LCD Title Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

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1 Page 1 of 14 Deborah Rondeau From: Saved by Windows Internet Explorer 7 Sent: Saturday, August 23, :42 PM Subject: NGS LCD for Incision and Drainage (I & D) of Abcess of Skin, Subcutaneous and Accessory Structures (L28206) LCD for Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures (L28206) Contractor Information Contractor Name National Government Services, Inc. Contractor Number MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY Part B MAC NY Part B Contractor Type MAC - Part A MAC - Part B LCD ID Number L28206 LCD Information LCD Title Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures Contractor's Determination Number L28206 AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental

2 Page 2 of 14 Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 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: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Publications: CMS Publication , Medicare Benefit Policy Manual, Chapter 15: 290 Foot Care Primary Geographic Jurisdiction MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY Part B MAC NY Part B Secondary Geographic Jurisdiction See Other Comments

3 Page 3 of 14 Oversight Region I, II Original Determination Effective Date For services performed on or after 07/18/2008 Original Determination Ending Date Revision Effective Date Revision Ending Date Indications and Limitations of Coverage and/or Medical Necessity This LCD consolidates and replaces all previous policies and publications on this subject by the carrier and fiscal intermediary predecessors of National Government Services in New York (National Government Services, GHI and HealthNow) and First Coast Service Options in Connecticut. This LCD is effective for Downstate New York Part B on July 18, 2008; for Connecticut Part B on August 1, 2008; for Upstate New York Part B on September 1, 2008; for New York and Connecticut Part A on November 14, Abstract: 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

4 Page 4 of 14 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; an abscess requiring packing after the incision and drainage. In these circumstances, at minimum, locally injected anesthesia is usually required. Indications: 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 coded as an I&D procedure. It should be coded using CPT code 11730, avulsion of nail plate, partial or complete, simple; single. When incision and drainage is performed for treatment of paronychia or other infectious processes of the foot without avulsion or resection of the toenail, incision and drainage services CPT codes 10060, or should be used. Limitations: 1. Use of incision and drainage of abscess codes (CPT codes 10060, 10061) is limited to lesions with documented abscess and/or pus collection. Use of these codes 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. 2. 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

5 Page 5 of 14 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. 3. Partial or complete avulsion of the toenail is a common treatment for paronychia in association with an ingrown nail In fact, incision and drainage is not commonly performed for treatment of paronychia in the foot without avulsion of the toenail. This procedure usually effectively drains any associated infection. Therefore, the provider who performs this procedure to address a localized infection should bill the appropriate code 11730, and not one for an incision and drainage service. 4. Billing for incision and drainage procedures (CPT codes 10060, 10061, 10160) for treatment of paronychia of the foot when avulsion or resection of the toenail has been performed to treat the same condition, is not appropriate. 5. Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request. Then only the CPT codes 10060, 10061, should be used and not combined with CPT codes or Incision and drainage services are not payable for treatment of blisters unless there is superinfection with pus and abscess formation. 7. For Podiatry (Specialty 48): Claims for CPT codes or with diagnosis of furuncle/carbuncle (680.7), suppurative hidradenitis (705.83) will be subject to review, as these diagnoses are not commonly found in the foot. CPT codes 10060, or are payable for ICD-9-CM codes , , 682.7, and only. CPT code is payable only for ICD-9-CM codes , , and Anesthesia administered by or "incident to" the physician performing the I&D procedure is included in the reimbursement for incision and drainage services and is not separately payable. Other Comments: For claims submitted to the fiscal intermediary: This coverage determination

6 Page 6 of 14 also applies within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims. Bill type codes only apply to providers who bill these services to the fiscal intermediary. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. Coverage Topic Surgical Services 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. 13x 71x Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) Clinic-rural health 73x Clinic-independent provider based FQHC (eff 10/91) 85x Revenue Codes: Special facility or ASC surgery-rural primary care hospital (eff 10/94) 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

7 Page 7 of 14 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. Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X. 036X 049X 051X 076X 096X Operating room services-general classification Ambulatory surgical care-general classification Clinic-general classification Treatment or observation room-general classification Professional fees-general classification CPT/HCPCS Codes INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE

8 Page 8 of INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION ICD-9 Codes that Support Medical Necessity It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9- CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination DISEASES OF LIPS INFLAMMATORY DISEASE OF BREAST INFECTIONS OF NIPPLE ASSOCIATED WITH CHILDBIRTH UNSPECIFIED AS TO EPISODE OF CARE INFECTIONS OF NIPPLE ASSOCIATED WITH CHILDBIRTH DELIVERED WITH OR WITHOUT ANTEPARTUM CONDITION INFECTIONS OF NIPPLE ASSOCIATED WITH CHILDBIRTH DELIVERED WITH POSTPARTUM COMPLICATION ANTEPARTUM INFECTIONS OF NIPPLE POSTPARTUM INFECTIONS OF NIPPLE ABSCESS OF BREAST ASSOCIATED WITH CHILDBIRTH UNSPECIFIED AS TO EPISODE OF CARE ABSCESS OF BREAST ASSOCIATED WITH CHILDBIRTH DELIVERED WITH OR WITHOUT ANTEPARTUM CONDITION ABSCESS OF BREAST ASSOCIATED WITH CHILDBIRTH DELIVERED WITH POSTPARTUM COMPLICATION ANTEPARTUM ABSCESS OF BREAST POSTPARTUM ABSCESS OF BREAST CARBUNCLE AND FURUNCLE OF NECK CARBUNCLE AND FURUNCLE OF TRUNK

9 Page 9 of CARBUNCLE AND FURUNCLE OF UPPER ARM AND FOREARM CARBUNCLE AND FURUNCLE OF HAND CARBUNCLE AND FURUNCLE OF BUTTOCK CARBUNCLE AND FURUNCLE OF LEG EXCEPT FOOT CARBUNCLE AND FURUNCLE OF FOOT CARBUNCLE AND FURUNCLE OF OTHER SPECIFIED SITES CARBUNCLE AND FURUNCLE OF UNSPECIFIED SITE UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER FELON ONYCHIA AND PARONYCHIA OF FINGER UNSPECIFIED CELLULITIS AND ABSCESS OF TOE ONYCHIA AND PARONYCHIA OF TOE CELLULITIS AND ABSCESS OF UNSPECIFIED DIGIT CELLULITIS AND ABSCESS OF FACE CELLULITIS AND ABSCESS OF NECK CELLULITIS AND ABSCESS OF TRUNK CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB CELLULITIS AND ABSCESS OF BUTTOCK CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES CELLULITIS AND ABSCESS OF OTHER SPECIFIED SITES CELLULITIS AND ABSCESS OF UNSPECIFIED SITES PILONIDAL CYST WITH ABSCESS HIDRADENITIS SEBACEOUS CYST OTHER SPECIFIED DISORDERS OF SKIN BLISTER OF FOOT AND TOE(S) INFECTED

10 NGS LCD for Incision and Drainage (I & D) of Abcess of Skin, Subcutaneous and Acc... Page 10 of HEMORRHAGE COMPLICATING A PROCEDURE HEMATOMA COMPLICATING A PROCEDURE SEROMA COMPLICATING A PROCEDURE INFECTED POSTOPERATIVE SEROMA OTHER POSTOPERATIVE INFECTION Diagnoses that Support Medical Necessity ICD-9 Codes that DO NOT Support Medical Necessity ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity General Information Documentation Requirements The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-9-CM codes will be returned. The patient's medical record must document the signs/symptoms exhibited by the patient that required the incision and drainage procedure. This information must be available in the patient's record, if requested for review purposes. Additional information such as photographs, operative reports, or progress notes may be required from any provider who demonstrates a pattern of billing repeated incision and drainage services of the same anatomical area. The pre-operative size, location and appearance of any abscess, hematoma or other lesion claimed to have undergone an incision and drainage service must be clearly documented in the medical record.

11 NGS LCD for Incision and Drainage (I & D) of Abcess of Skin, Subcutaneous and Acc... Page 11 of 14 The operative note must include a description of the procedure, e.g. equipment used, and the approximate quantity (e.g., 1 cc, 5 ml) and quality (e.g., serous, sero-sanguinous, bloody, exudative, frank pus, malodorous) of the material drained from the collection. Since the majority of hematomas, seromas and cysts do not require incision and drainage or aspiration, and since this procedure can actually increase the risk of infection, providers reporting these services must document the size, location and quantity of blood, material or serosanguinous fluid drained, as well as the medical necessity of the procedure, (e.g. severe pain or infection and failure to resolve with conservative measures). Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request. The Medicare Administrative Contractor retains the right to require of select providers photographic documentation of lesions prior to and/or after treatment if there are indications of abuse of any of the codes in this policy. Providers will be notified of this requirement individually and prior to such a requirement being instituted. If a patient requires incision and drainage services repeatedly (more than once) for treatment of abscess in the same anatomic location, the medical record must clearly reflect the reason(s) for persistent or recurrent infection and what measures are being taken to avoid infections. Documentation must be available to Medicare upon request. Appendices Utilization Guidelines A single drainage procedure for most abscesses, hematomas or other collections is often curative. It would be unusual for any individual lesion or collection to require more than two such services. Recurrent fluid or abscess collections or repeated need for I&D services may indicate the need for additional medical or surgical measures to provide definitive treatment. Multiple abscesses or fluid collections in the same patient requiring drainage, more than two times per year in the same location is uncommon. Services

12 NGS LCD for Incision and Drainage (I & D) of Abcess of Skin, Subcutaneous and Acc... Page 12 of 14 exceeding this parameter will be considered not medically necessary. Sources of Information and Basis for Decision This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below. 1. Other contractors' local medical review policies/local coverage determinations: Empire NY, Policy #Surg26, effective 10/30/98 Upstate Medicare Division, Policy #S97-9, effective 12/01/97 Rhode Island, effective 12/15/ "Ingrown Toenails" from accessed 12/12/ Chapters on Paronychia, Subungual Hematoma, Subungual Ecchymosis and Cutaneous Abscess or Pustule, from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES Longwood Information LLC 4822 Quebec St NW Washington DC all found at accessed 12/12/ Articles titled Hidradenitis Suppurativa (Fite, D.), Ingrown Toenails (Benzoni T.), Hand Infections (Schantz, AK, and Bailey, H.), Paronychia (Murphy-Lavoie, H. and Haydel, M.), from accessed 12/12/ Bondi E, Jegasothy B, Lazarus G. Dermatology:Diagnosis and Therapy. Lange Clinical Manual. Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia. 6. Nealon, TE. Fundamentals Skills in Surgery, 3rd Edition, W.B.Saunders Co. 7. Odom, Richard B., M.D., James, William D., M.D. & Berger, Timothy G., M.D. Andrews' Diseases of the Skin Clinical Dermatology (9th ed.) Saunders An Imprint of Elsvier 8. Freedberg, Irwin M., M.D. (editor), Eisen, Arthur Z., M.D. (editor), Wolff, Klaus, M.D., DSc(Hon)(editor), Austen, K. Frank, M.D. (editor), Goldsmith, Lowell A., M.D. (editor), Katz, Stephen, I., M.D., PhD,

13 NGS LCD for Incision and Drainage (I & D) of Abcess of Skin, Subcutaneous and Acc... Page 13 of 14 (editor), Fitzpatrick, Thomas, B., M.D., PhD, DSc (Hon) (editor). Fitzpatrick's Dermatology In General Medicine (5th ed.)(vol 1, p. 884). McGraw-Hill Advisory Committee Meeting Notes Carrier Advisory Committee Meeting Date(s): New York: 02/02/2005 This coverage determination does not reflect the sole opinion of the contractor or contractor Medical Director. Although the final decision rests with the contractor, this determination was developed in consultation with representatives from Advisory Committee members and/or from various state and local provider organizations. Any Carrier Advisory Committee (CAC) related information, including Start Date and End Date of Comment Period, reflects the last time this LCD passed through the Comment and Notice process. Formal comment is not required for LCDs being adopted as part of the MAC transition. Start Date of Comment Period 02/02/2005 End Date of Comment Period 03/18/2005 Start Date of Notice Period 06/03/2008 Revision History Number Revision History Explanation This LCD is effective for Downstate New York Part B on July 18, 2008; for Connecticut Part B on August 1, 2008; for Upstate New York Part B on September 1, 2008; for New York and Connecticut Part A on November 14, The CMS Statement of Work for the J13 Medicare Administrative Contract

14 NGS LCD for Incision and Drainage (I & D) of Abcess of Skin, Subcutaneous and Acc... Page 14 of 14 (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This NGS policy is being promulgated to the J13 MAC as the most clinically appropriate LCD within that jurisdiction. The NGS roster of LCDs has been developed under the combined experience of seven Medicare contractor medical directors. The criteria for inclusion in this roster includes areas of identified CERT errors, especially repetitive errors; high volume/high dollar/pervasive problems; patient safety issues; potential for automation; beneficiary access to new technology; implementation of NCD; narrative medical necessity parameters for medical review and provider education; and CMS/law enforcement mandates. The previous approximately 175 legacy Empire LCDs were reviewed by the seven NGS medical directors, and those LCDs thought not to be clinically appropriate or effective have been retired and are excluded from the current roster of NGS LCDs. The remaining currently effective legacy Empire LCDs identified as appropriate and clinically effective by the criteria listed above, are being retained as most clinically appropriate until they are incorporated into the ongoing policy consolidation process for NGS. This LCD has undergone advice and comment from providers in New York, New Jersey, Connecticut and Delaware. This advice and comment process, because of its larger scope, has ensured the most clinically appropriate policy for the J13 MAC jurisdiction. Reason for Change Last Reviewed On Date 06/03/2008 Related Documents A Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures Supplemental Instructions Article LCD Attachments There are no attachments for this LCD