Incision and drainage

Patient admitted for neck abscess goes to the OR for I&D. Surgeon I&D and takes a culture and irrigates with saline and pack. Can I code therapeutic and diagnostic for my procedure?


  • Anyone has guidance on this question?

  • This may be a little different, but my understanding is that if there is a therapeutic and diagnostic component, you only code the therapeutic.

    Coding Clinic 3Q2017, p12

    Question: A 64-year-old patient with new onset ascites presents for abdominal paracentesis. An ultrasound guided diagnostic and therapeutic paracentesis are both performed via a catheter. Is it appropriate to report two procedure codes for the diagnostic and therapeutic paracentesis?

    Answer: Assign only the following code:

    0W9G3ZZ Drainage of peritoneal cavity, percutaneous approach, for the diagnostic and therapeutic paracentesis

    If there is a therapeutic component to the procedure, only the qualifier “Z” is used, rather than the qualifier “X.” The qualifier “X” is exclusively used for diagnostic procedures only. If there are two separate procedures, one diagnostic and the other therapeutic, then both procedures are code separately. For example, a diagnostic drainage procedure that uses a different approach or samples a different site from the therapeutic drainage procedure requires two separate codes to capture both the diagnostic procedure (biopsy) and the therapeutic procedure.

    Copyright (~Year), American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

  • Thank you for your response! My thought is if you I&D an abscess... to relieve pressure and pain the patient is experiencing and collect a culture. the qualifier for the procedure should be "Z". This makes a big difference between a medical and surgical DRG. Only one incision is made.... Patient already on antibiotics prior to I&D. I just want to make sure I'm interpreting correctly.... Any other guidance would be appreciated.

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