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I&D for Cutaneous Abscess
I am new to Dermatology coding and need help with this procedure note: An I&D was performed on the left hand for a cutaneous abscess. Consent was obtained and risks were reviewed including but not limited to delayed wound healing, infection, need for multiple I and D's, and pain. The area was prepped in the usual clean fashion. Local anesthesia was achieved with 2 cc of 1% carbocaine. The abscess was incised with a 15 blade, and pressure was applied to the wound to drain the underlying contents. Aquaphor and a dry sterile dressing were applied and wound care was reviewed. Can you tell me what CPT code I should use?
Question:
I am new to Dermatology coding and need help with this procedure note: An I&D was performed on the left hand for a cutaneous abscess. Consent was obtained and risks were reviewed including but not limited to delayed wound healing, infection, need for multiple I and D's, and pain. The area was prepped in the usual clean fashion. Local anesthesia was achieved with 2 cc of 1% carbocaine. The abscess was incised with a 15 blade, and pressure was applied to the wound to drain the underlying contents. Aquaphor and a dry sterile dressing were applied and wound care was reviewed. Can you tell me what CPT code I should use?
Answer:
Welcome to Dermatology coding! We are happy to help you. In this note, the physician is performing an incision and drainage. The physician incised the abscess and drained the abscess. Typically, a simple I&D involves a single lesion or abscess just below the skin’s surface. The correct CPT code to report is 10060 (incision and drainage of abscess) and the diagnosis code is L02.512 (Cutaneous abscess of left hand).
*This response is based on the best information available as of 7/31/25.
Wart Destruction with Liquid Nitrogen
A saw an established patient who I say for evaluation of a wart on the arm. The wart is moderate in severity. I evaluated the wart, performed a skin exam and removed the wart with liquid nitrogen and told the patient to come back PRN. My coder tells me I can only report the wart destruction and not a visit code. Is that correct?
Question:
I saw an established patient who I see for evaluation of a wart on the arm. The wart is moderate in severity. I evaluated the wart, performed a skin exam and removed the wart with liquid nitrogen and told the patient to come back PRN. My coder tells me I can only report the wart destruction and not a visit code. Is that correct?
Answer:
It appears the focus of the visit is the removal of the wart (17110). Unless you have a significant separately identifiable E/M service, the E/M service would be inherent to the procedure. Keep in mind the procedure includes pre-service work which is the E/M service. Only the procedure should be reported in the situation you described.
*This response is based on the best information available as of 7/17/25.
Cancer Surveillance E/M
My physician saw an established patient for follow-up in the office for cancer surveillance. The patient is doing well and no treatment is indicated. In addition, the physician removes a benign lesion on the right anterior neck (1.1 cm) and the patient is being treated for a rash that is acute. The physician recommends cleansers and moisturizers and prescribes a topical steroid. What codes should be billed?
Question:
My physician saw an established patient for follow-up in the office for cancer surveillance. The patient is doing well and no treatment is indicated. In addition, the physician removes a benign lesion on the right anterior neck (1.1 cm) and the patient is being treated for a rash that is acute. The physician recommends cleansers and moisturizers and prescribes a topical steroid. What codes should be billed?
Answer:
An E/M is supported for cancer surveillance and treating the rash. The problems addressed are low complexity (1 acute uncomplicated and 1 stable chronic) with moderate risk (prescription drug management). The level supported is 99213-25. CPT code 11422 is reported for the benign lesion excision on the right anterior neck.
*This response is based on the best information available as of 7/03/25.
Aquaphor and UVB Billing
Some of our dermatology physicians use Aquaphor as a conductive agent when doing UVB for our psoriasis patients and billing CPT code 96910. We see that Aquaphor is not considered a conductive agent, but we wanted to get your feedback to make sure. Should we use CPT code 96910 or 96912?
Question:
Some of our dermatology physicians use Aquaphor as a conductive agent when doing UVB for our psoriasis patients and billing CPT code 96910. We see that Aquaphor is not considered a conductive agent, but we wanted to get your feedback to make sure. Should we use CPT code 96910 or 96912?
Answer:
First, Aquaphor is not a conductive agent. It is very clear from the CPT guidance that 96910 (photochemotherapy) is reported with tar and ultraviolet B rays (Goeckerman treatment) or petrolatum and ultraviolet B rays. If you use Psolarens, the correct code to report is 96912. If other substances or no substance is used, you report 96900 (Actinotherapy (ultraviolet light)). Aquaphor would fall into that category.
*This response is based on the best information available as of 6/19/25.
Incident-To Billing for Medicare
I was told for our Medicare patients in order for my PA to report incident-to the physician, that the supervising physician must be in the office. Is that correct? We are billing new and established patients under a physician’s NPI number even if there is no physician in the office
Question:
I was told for our Medicare patients in order for my PA to report incident-to the physician, that the supervising physician must be in the office. Is that correct? We are billing new and established patients under a physician’s NPI number even if there is no physician in the office.
Answer:
To bill Incident-to services a physician must be in the office suite, but it does not need to be the Advanced Practice Provider’s (APPs) supervisor. In addition, you cannot bill incident-to for a new patient when the APP sees them. “Incident To” can only occur for an established patient with an established plan of care originally developed by a physician. If the plan of care changes or the patient has a new or worsening problem, it must be billed under the APP's NPI number. For Medicare, when billing under the APPs NPI number 85% is paid under the Medicare Physician Fee Schedule.
*This response is based on the best information available as of 6/05/25.
Billing for a Simple Repair of the Scalp
My physician is billing a simple repair of the scalp with CPT code 12001 when he uses steri-strips to do the repair. I don’t believe this is correct. Can we report the use of steri-strips alone to report a simple repair?
Question:
My physician is billing a simple repair of the scalp with CPT code 12001 when he uses steri-strips to do the repair. I don’t believe this is correct. Can we report the use of steri-strips alone to report a simple repair?
Answer:
According to CPT guidelines, repairs are reported when the provider utilizes sutures, staples, or tissue adhesives either singly or in combination with each other, or in combination with adhesive strips. Repairs utilizing adhesive strips alone are not separately reportable. They are part of the E/M service.
*This response is based on the best information available as of 5/22/25.
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