2025 CPT code 10180
(Active) Effective Date: N/A Revision Date: N/A Surgery - Incision and Drainage Procedures Surgery Feed
Incision and drainage (I&D) of a complex wound infection.
Modifiers may be applicable based on the circumstances of the procedure.For example, modifier 22 (Increased Procedural Services) might be used if the complexity exceeds the typical definition of the code, or modifier 51 (Multiple Procedures) if multiple separate I&D procedures are performed on the same day.
Medical necessity for incision and drainage is established when a patient presents with a localized collection of pus (abscess) or other infected material that requires surgical intervention for drainage to prevent spreading of the infection, improve healing, and alleviate symptoms. Documentation must support the clinical indication for the procedure.
The physician is responsible for all aspects of the procedure, including pre-operative preparation, incision, drainage, irrigation, wound packing or closure, and post-operative care instructions.
In simple words: The doctor cuts open and drains an infected area, cleans it thoroughly, and may pack it with gauze to help it heal.If the infection is severe or in a complex area, the procedure might take longer and require more skill.
This CPT code encompasses the incision and drainage of a complex wound infection.The procedure involves cleaning the operative site with an antiseptic, possibly injecting a local anesthetic (e.g., lidocaine). The provider then incises the infected area, drains the fluid collection, and performs copious irrigation with a solution like normal saline to remove debris.Further irrigation with an antibiotic solution may be used, followed by packing the wound with gauze to prevent leakage and promote drainage.Wound closure may be done in layers around a drain or allowed to heal by secondary intention. A complex procedure is characterized by multiple incisions, drain placements, extensive packing, or a more complicated wound closure than a simple I&D.The increased complexity warrants additional time and expertise.
Example 1: A patient presents with a large, fluctuant abscess on their thigh.The physician performs an incision and drainage, irrigating the wound thoroughly with saline and an antibiotic solution before packing it with gauze.The patient is instructed on wound care and signs of infection., A patient with a complex wound infection requiring multiple incisions and drain placement following a surgical procedure.The physician performs an extensive I&D, placing multiple drains and using extensive packing techniques due to the complexity of the infection.The patient receives appropriate post-operative wound care instructions., A patient presents with a deep, complicated wound infection near a joint.The physician performs a complex I&D, requiring additional expertise and time due to the location and depth of the infection.The patient is closely monitored for complications and receives detailed wound care instructions.
Detailed documentation should include the size and location of the wound, the amount and type of drainage, the irrigation solutions used, and the type of wound closure or packing.Pre- and post-operative assessments, including photographs, are essential for accurate coding and medical record completeness.Any complications or unexpected findings should be thoroughly documented.
** Always ensure accurate documentation and adhere to current coding guidelines to ensure appropriate reimbursement.
- Revenue Code: P6A (MINOR PROCEDURES - SKIN)
- RVU: Information not available.RVUs vary based on geographic location, facility type, and other factors. Consult the appropriate fee schedule for current values.
- Global Days: Information not available in provided data.The global period depends on the specific procedure and payer guidelines.
- Payment Status: Active
- Modifier TC rule: The information provided does not specify whether a technical component (TC) modifier applies.Consult the most up-to-date guidelines and fee schedules for clarification.
- Fee Schedule: Fee schedules vary by payer and geographic location.Consult current fee schedules for the most accurate reimbursement rates.
- Specialties:General Surgery, Plastic Surgery, Emergency Medicine
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center, Urgent Care Facility, Emergency Room - Hospital