CPT Code and Description
10040 – Acne Surgery (Eg, Marsupialization, Opening Or Removal Of Multiple Milia, Comedones, Cysts, Pustules).
10060 – Incision And Drainage Of Abscess (Eg, Carbuncle, Suppurative Hidradenitis, Cutaneous Or Subcutaneous Abscess, Cyst, Furuncle, Or Paronychia); Simple Or Single.
10061 – Incision And Drainage Of Abscess (Eg, Carbuncle, Suppurative Hidradenitis, Cutaneous Or Subcutaneous Abscess, Cyst, Furuncle, Or Paronychia); Complicated Or Multiple.
Fee amount from Top Insurance:
| Insurance | CPT 10040 | CPT 10060 | CPT 10061 |
| Medicare | $107.16 | $116.39 | $198.33 |
| Aetna | $95.00-$105.00 | $142.50-$157.50 | $190.00-$210.00 |
| Anthem | $97.50-$102.50 | $146.25-$153.75 | $195.00-$205.00 |
| Blue Cross Blue Shield | $96.00-$104.00 | $144.00-$156.00 | $192.00-$208.00 |
| Cigna | $98.00-$103.00 | $147.00-$153.00 | $196.00-$204.00 |
| Humana | $96.50-$103.50 | $144.75-$155.25 | $193.50-$206.50 |
| Kaiser Permanente | $97.00-$103.00 | $145.50-$154.50 | $194.00-$206.00 |
| Medicaid | $95.00-$105.00 | $142.50-$157.50 | $190.00-$210.00 |
| UnitedHealthcare | $98.50-$103.50 | $147.75-$152.25 | $196.50-$203.50 |
| WellCare | $96.00-$104.00 | $144.00-$156.00 | $192.00-$208.00 |
Common Questions and Answers:
Question: Is acne surgery covered by Medicare?
Answer: Generally, acne surgery for cosmetic purposes is not covered. However, if there is a medical necessity, it may be covered.
Question: Can I use modifier -59 for all these codes?
Answer: Use modifiers judiciously to indicate distinct procedural services. Modifier usage should align with Medicare guidelines.
Question: What is the difference between CPT codes 10060 and 10061?
Answer: The primary difference is the complexity of the abscess. Code 10060 is for simpler abscesses, while code 10061 is for complex, extensive abscesses.
Question: Can I bill separately for supplies and anesthesia used during these procedures?
Answer: Billing for supplies and anesthesia may be subject to Medicare rules. Check the MPFS and Medicare guidelines for specifics.
Medicare appeal and response
Comment: A commenter stated if paronychia is considered a nail margin inflammation, then removing a
portion of the nail plate and relieve the pressure with packing is appropriate. However, if there is an
infection, then an incision and drainage is needed. CPT code 10060 or 10061 is appropriate in this case.
Response: We agree if an infection is present and incision and drainage is necessary, then it is
appropriate to report CPT code 10060. If no infection is present, and the nail plate is removed to relieve
pressure, then it is inappropriate to use the incision and drainage CPT codes.
Comment: A commenter stated there are times when the nail (plate total or partial) needs to be avulsed
in order to perform the incision and drainage for the abscess. Therefore, CPT codes10060 or 10061 is the
appropriate and CPT code 11730 is incidental. This is consistent with the National Correct Coding
Initiative (NCCI) which bundles CPT code 11730 into CPT codes 10060 and10061. We believe the LCD
should be consistent with NCCI.
Response: If the avulsion of the nail plate alone is sufficient to drain the abscess, this is the service which
should be billed, (i.e. 11730). If, however, it is necessary to remove part of the nail plate in order to
complete the drainage of the abscess, then the incision and drainage codes are appropriate. We believe
this is appropriately explained in the LCD and no change is necessary.
Comment: A commenter questioned the utilization guideline which states “Multiple abscesses or fluid
collections in the same patient requiring drainage, more than two times per year in the same location is
uncommon. Services exceeding this parameter will be considered not medically necessary.” They could
imagine a patient with hidradenitis having recurrent abscesses. These patients are typically treated
with repeated incision and drainage procedures, more than two per year. The definition of hidradenitis
is that a patient has recurrent abscesses in the same location.
Response: We will revise the LCD to include ICD‐9‐CM code 705.83 (hidradenitis) as an exclusion to the
utilization guideline. The documentation must be clear as to the reason more definitive therapy is not
appropriate
