Abscess Incision and Drainage

CPT 10060
Approach Bedside
Add-on / Variant CPTs
  • 10061 — Complicated or multiple I&D
Preoperative Diagnosis:

Cutaneous abscess, [location: right forearm / left buttock / back / perianal / axilla / groin / other]

Postoperative Diagnosis:

Cutaneous abscess, [location]

Procedure Performed:

Incision and drainage of [location] abscess

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

Local: [X] mL 1% lidocaine without epinephrine [field block / ring block], [IV/IM sedation: ketamine / morphine as adjunct if needed]

Indications:

The patient is a [age]-year-old [male/female] with a [X]-day history of a [fluctuant / tender / erythematous] [location] abscess measuring approximately [X × X] cm presenting for incision and drainage. [History of recurrent MRSA / immunocompromise / diabetes noted.] The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.

Findings:

A [X × X] cm fluctuant, tender [location] abscess was identified. Following incision, [X] mL of [purulent / seropurulent / bloody-purulent] material was expressed and drained. No evidence of [fascial involvement / crepitus / tracking] was noted. The cavity measured approximately [X × X] cm in depth. No foreign body was identified.

Description of Procedure:

The patient was positioned comfortably to provide access to the [location]. The overlying skin was prepped with [betadine / ChloraPrep] and draped in sterile fashion. The skin and surrounding subcutaneous tissue were infiltrated with [X] mL of 1% lidocaine using a field block [or ring block], avoiding direct injection into infected tissue which may impair anesthetic effect.

Adequate anesthesia was confirmed by loss of sharp sensation. A [number] 11-blade [or 15-blade] scalpel was used to make a [linear / cruciate / elliptical] incision over the point of maximum fluctuance. The incision was extended to the full length of the abscess cavity. [X] mL of [purulent] material was expressed manually and by irrigation.

The cavity was explored with a gloved finger [or curved hemostat] to break up loculations and confirm the extent of the cavity. The cavity walls were curetted [with a curette] to disrupt the abscess wall. The cavity was thoroughly irrigated with [normal saline / dilute betadine] until clear return was obtained.

The cavity was loosely packed with [iodoform / plain] gauze [or a loop drain was placed] to maintain drainage. [No packing was placed. Wound left open.] A wound culture was [sent / not sent] per clinical judgment.

A dressing was applied over the packing. The patient was instructed on wound care, signs of worsening infection, and follow-up.

Complications:

None

Specimens:

Wound culture sent [aerobic and anaerobic] / [None — not indicated for uncomplicated community abscess]

Estimated Blood Loss:

Minimal

Drains:

[Iodoform gauze packing / plain gauze / loop drain / open wound, no packing]

Disposition:

The patient tolerated the procedure well. Instructions were given for [daily wet-to-dry dressing changes / follow-up for packing removal in [2–3] days]. Antibiotics [were / were not] prescribed. Return precautions were reviewed.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Cutaneous abscess, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Incision and drainage of *** abscess
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine field block

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** abscess x*** days. Fluctuant, tender, *** × *** cm. Consent obtained.

FINDINGS: *** × *** cm fluctuant abscess. *** mL *** material drained. No fascial involvement, crepitus, or tracking. Cavity *** × *** cm.

PROCEDURE:
Patient positioned. Site prepped and draped in sterile fashion. *** mL 1% lidocaine field block. Adequate anesthesia confirmed. *** blade incision over point of maximum fluctuance, extended to full cavity length. *** mL purulent material expressed. Cavity explored, loculations broken. Irrigated until clear. Packed with ***. Culture: ***.

COMPLICATIONS: None
DRAINS: *** packing
DISPOSITION: Wound care instructions given. Follow-up in *** days for packing removal. Antibiotics: ***.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Pilonidal Abscess

A pilonidal abscess overlying the sacrococcygeal region was drained. An off-midline incision was made to avoid the natal cleft. The cavity was explored and pits [were / were not] identified. Packing was placed. The patient was counseled that pilonidal disease is recurrent and that definitive surgical excision may be required after the acute infection resolves. Referral to general surgery for outpatient follow-up was provided.

Perianal Abscess

A perianal abscess was drained in the [left / right] [anterior / posterior] perianal region. Anoscopy was not performed at this time. The patient was counseled that 50% of perianal abscesses are associated with an underlying fistula-in-ano, and that they may develop a persistent draining sinus requiring further evaluation. Surgery follow-up was arranged. [Note: do not probe for fistula acutely — risk of creating a false passage.]

Loop Drain Placement (Large or Complex Abscess)

Given the large cavity size and risk of premature closure with packing, a vessel loop [or Penrose drain] was placed through the cavity as a loop drain. A second small stab incision was made on the contralateral aspect of the abscess, and the drain was threaded through the cavity and tied loosely externally. This maintains drainage while allowing the cavity to close from the inside out. The drain is advanced and shortened at each follow-up visit.

Charting Tips
  • Document whether fascial involvement, crepitus, tracking, or systemic toxicity was present or absent. This drives the decision between bedside I&D and operative debridement for necrotizing soft tissue infection. Explicit documentation of 'no crepitus, no fascial involvement' protects against claims of delayed diagnosis of necrotizing fasciitis.
  • For perianal abscesses, document that fistula probing was deferred — creating a false passage by acute probing is a recognized complication and should not be attempted at the time of I&D.
  • Wound culture practice: most guidelines do not require culture for uncomplicated community-acquired abscesses in immunocompetent patients. Document your decision and the rationale (risk factors for MRSA, immunocompromise, failure of prior antibiotics).
Billing Tips
  • Bill 10060 for simple or single abscess I&D (1.19 wRVU, 10-day global). Use for uncomplicated superficial abscesses drained in a single location.
  • Bill 10061 for complicated or multiple abscesses (2.39 wRVU, 10-day global). Use when the abscess is complex (multiloculated, large cavity requiring packing) or when multiple separate abscesses are drained in the same session. Document why complexity qualifies.
  • 10-day global period: wound checks within 10 days are bundled. Do not bill a separate E/M for routine packing changes or wound checks unless a new, unrelated problem is addressed.
  • If imaging guidance (ultrasound) is used to localize a deep abscess before incision, 76942 can be billed separately. Document real-time imaging and a permanent record of needle placement.
  • Pilonidal abscesses use 10080 (simple) or 10081 (complicated), not 10060/10061. Anorectal abscesses use 46040 or 46060 depending on location. Do not use the generic skin codes for these.