2025 CPT code 10160
(Active) Effective Date: N/A Surgery - Incision and Drainage Procedures on the Skin, Subcutaneous and Accessory Structures Surgery Feed
Puncture aspiration of abscess, hematoma, bulla, or cyst.
Modifiers may be applicable in certain circumstances.Modifier 52 may be used if the procedure is reduced in scope, modifier 73 for discontinued procedure prior to anesthesia, modifier 74 for discontinued after anesthesia, and so on.The appropriate modifier should be appended based on the specific scenario.
Medical necessity must be established by documenting the presence of a symptomatic lesion requiring aspiration for diagnostic or therapeutic purposes. The documentation should support the need for the procedure to relieve pain, prevent complications, or guide treatment decisions.
The physician is responsible for cleaning and prepping the skin, performing the aspiration, collecting the sample (if needed), applying any necessary dressings or medications, and providing post-procedure instructions to the patient.
In simple words: The doctor uses a needle to drain fluid or pus from a lump or blister under the skin. This helps identify the cause of the lump and may also help it heal.
This code describes a procedure where a needle is inserted into a skin lesion (abscess, hematoma, bulla, or cyst) to aspirate fluid or pus, often for culture or to relieve pressure.It involves cleaning and isolating the area, inserting the needle, withdrawing the fluid, and applying a dressing and/or antibiotics.
Example 1: A patient presents with a painful, fluctuant abscess on their arm. The physician uses code 10160 to aspirate the pus for culture and sensitivity testing to guide antibiotic treatment., A patient has a large bulla (blister) filled with clear fluid. The physician performs a puncture aspiration (10160) to relieve discomfort and promote healing., Following trauma, a patient develops a hematoma beneath the skin. The physician performs 10160 to drain the accumulated blood and reduce pressure.
Documentation should include the location, size, and nature of the lesion, the method of aspiration, the amount and appearance of the aspirated material, any cultures taken, and any complications encountered.
- Revenue Code: P6A (Minor Procedures - Skin)
- Payment Status: Active
- Specialties:Family Medicine, Internal Medicine, General Surgery, Dermatology, Emergency Medicine
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, Emergency Room - Hospital,Ambulatory Surgical Center,Other Place of Service