Urgent Incision and Drainage

“I saw a patient at the wound care clinic, and he presented with an abscess that required urgent incision and drainage. I sent him directly to the emergency room for admission, work-up for sepsis and later that evening performed an incision of the 3rd intermetatarsal space, bone biopsy of the third metatarsal and application of a wound vac. I followed him while he was admitted. I am not sure how to code the initial visit in the wound care clinic. I am not sure about modifiers for the “decision for surgery.” Can I bill for the subsequent daily rounding and changes of the VAC while he was admitted? Could you please advise the proper billing?”

So, a patient is seen in a wound care clinic with an abscess that requires an urgent I&D to be performed. The patient was sent directly to the ER after he was evaluated at the wound care clinic. He was admitted to the hospital. He was worked up for sepsis. Later in the evening, an I&D was performed within the 3rd interspace. Additionally, a bone biopsy was performed of the 3rd metatarsal and a wound vac was applied. How would this scenario be coded?

As far as the patient encounter in the wound care clinic is concerned, using the 2021 E/M coding guidelines for office and other outpatient places of service, I would access the Elements of Medical Decision-Making Table. Under “Number and Complexity of Problems,” this would be classified as “Moderate” based upon “1 undiagnosed new problem with uncertain prognosis.” Under “Risk of Complications and/or Morbidity of Mortality of Patient Management,” this would be classified as a “Moderate risk of morbidity from additional diagnostic testing or treatment” based upon the “Decision regarding minor surgery with identified patient or procedure risk factors.” Since this appears to be an initial encounter with this patient (ie. a new patient), this would qualify to be billed as CPT 99204.

As far as the appropriate modifier to append to the E/M service for the “decision for surgery,” this is based upon the procedure or procedures that were subsequently performed following the E/M service.

With respect to the incision and drainage that was performed within the 3rd interspace, the most appropriate CPT code to bill is CPT 28002 which is defined as the following: Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space. As far as the bone biopsy of the 3rd metatarsal is concerned, the most appropriate CPT code to bill is CPT 20240 which is defined as the following: Biopsy, bone, open: superficial (eg. Sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, METATARSAL, carpal, metacarpal, phalanx).

One would think that E/M code 99204 should be appended by the 57 modifier to indicate the “decision for surgery,” However, the 57 modifier would be appended to the E/M code if one of the CPT/procedure codes that was subsequently performed was classified as a “Major” surgical procedure. That is, one that has a postoperative global period of 90 days. Since both CPT 28002 and CPT 20240 both have postoperative global periods of 10 days and are therefore classified as “Minor” surgical procedures, the 25 modifier would be the correct modifier to append to E/M code 99204. As discussed multiple times in the past, the 25 modifier is defined as the following: SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PHYSICIAN ONTHE SAME DAY OF THE PROCEDURE OR OTHER SERVICE – It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable (0 service above and beyond the other service provided or beyond the usual pre and postoperative care associated with the procedure that was performed.

The application of the VAC and any subsequent “changes of the VAC” would not be separately reimbursable as this is an integral part of the procedure that was performed and is directly related to the procedure.

As far as “daily rounding” is concerned while the patient is admitted to the hospital, since the CPT/procedure codes in question both have a postoperative global period of 10 days, the “daily rounding” is not reimbursable as these postoperative visits are an integral part of the surgical procedure(s).

The coding scenario would be the following:
CPT 99204 – 25
CPT 20240 – RT/LT
CPT 28002 – 59, RT/LT

This is my opinion.

Michael G. Warshaw, DPM, CPC