10060

Incision and drainage of abscess, simple or single

CPT code 10060 describes the incision and drainage of a simple or single abscess. This procedure involves making an incision into a localized collection of pus (abscess) within the cutaneous or subcutaneous tissue to allow for the release and removal of purulent material. Examples of conditions treated under this code include carbuncle, suppurative hidradenitis (simple, localized flare), cutaneous or subcutaneous abscess, cyst (when secondarily infected and forming an abscess), and furuncle. The term "simple or single" implies that the abscess is superficial, well-localized, and does not involve complex anatomical structures, multiple interconnected tracts, or require extensive dissection. The procedure aims to relieve pain, reduce inflammation, promote healing, and prevent the spread of infection.

Clinical Indications

  • Presence of a localized, fluctuant cutaneous or subcutaneous abscess, carbuncle, or furuncle.
  • Pain, tenderness, erythema, and swelling associated with a mature abscess.
  • Failure of conservative management (e.g., warm compresses, antibiotics alone for localized abscesses) to resolve the infection.
  • Clinical signs of pus collection that is ready for drainage.
  • Acute exacerbation of simple suppurative hidradenitis with a drainable abscess.

Procedure Steps

  1. Patient assessment, confirmation of abscess site, and obtain informed consent.
  2. Establish a sterile field around the abscess using aseptic technique.
  3. Administer local anesthesia (e.g., lidocaine with or without epinephrine) to the skin overlying the abscess.
  4. Make a small incision over the most fluctuant or dependent part of the abscess using a scalpel.
  5. Gently explore the cavity with a hemostat or probe to break up loculations and facilitate complete drainage of pus and necrotic debris.
  6. Collect a sample of purulent material for culture and sensitivity testing, if indicated.
  7. Irrigate the abscess cavity with saline solution.
  8. Pack the cavity loosely with plain or iodoform gauze to facilitate continued drainage and prevent premature skin closure (optional, based on physician preference and abscess size/depth).
  9. Apply a sterile dressing to the wound.
  10. Provide post-procedure instructions for wound care, dressing changes, and signs of infection, and schedule follow-up.

Coding Guidelines

  • This code has a 10-day global surgical period, meaning subsequent related care during this period is typically included in the original fee.
  • Code 10060 is for a 'simple or single' abscess. For a 'complicated or multiple' abscess, use CPT code 10061.
  • A 'complicated' abscess (10061) typically involves extensive packing, debridement of necrotic tissue, multiple incisions, or more complex anatomical locations. Documentation must support the higher level of complexity.
  • If multiple *simple* abscesses are drained at *different* anatomical sites during the same encounter, code 10060 may be reported multiple times with modifier 59 (Distinct Procedural Service) appended to the additional units.
  • Do not use 10060 for incision and drainage of specific abscesses for which dedicated CPT codes exist (e.g., peritonsillar, perianal, pilonidal cyst, breast abscess, appendiceal abscess).
  • The documentation should clearly describe the location, size, depth, nature of the exudate, method of anesthesia, and whether packing was used.

Associated ICD-10 Codes