O91.13 — Abscess of breast associated with lactation
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record must include relevant history, physical exam, and signs/symptoms that required the I&D procedure; diagnostic test results or the symptoms prompting tests must be recorded.
- Pre-operative documentation must record size, location and appearance of the abscess/collection; the operative note must describe the procedure, equipment used, and approximate quantity (e.g., 1 cc, 5 ml) and quality (e.g., serous, bloody, frank pus) of material drained.
- If multiple or repeated I&Ds are performed for the same anatomic area, records must explain reasons for recurrence and measures taken to prevent recurrence; photographic or operative documentation may be requested for patterns suggestive of abuse.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Key Coverage Criteria
- Incision and drainage (I&D) is covered when medical record documents an abscess, hematoma, seroma or other collection of the skin/subcutaneous/accessory structures requiring drainage with signs/symptoms that justify the procedure (e.g., evidence of infection, frank pus, severe pain, or failure of conservative measures).
- For podiatry (specialty 48), CPT codes 10060, 10061 or 10160 are payable when billed with ICD-10-CM codes L02.611, L02.612 or L98.8 only.
- CPT code 10140 is payable only when billed with the specified ICD-10-CM codes listed in the policy (multiple S- and L- codes for traumatic or specific skin conditions as enumerated).
- Incision and drainage (I&D) is covered for treatment of abscesses, defined as a circumscribed collection of pus in any location causing infection.
- I&D of non-abscess fluid collections (e.g., hematoma, seroma, cyst, bulla) is covered when medically necessary because of pain, inflammation, or infection.
- I&D is covered for specific clinical entities including carbuncle, suppurative hidradenitis (hidradenitis suppurativa), cutaneous or subcutaneous abscess, furuncle, post-operative wound infections, and paronychia when criteria for abscess or medical necessity are met.
2 Active Policies
A56766 — Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
L33563 — Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures
J06
Related Codes
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