How To Use CPT Code 22010

CPT 22010 describes the procedure of incision and drainage of a deep abscess in the posterior spine, specifically in the cervical, thoracic, or cervicothoracic region. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 22010?

CPT 22010 is a code used to describe the incision and drainage procedure performed by a healthcare provider to relieve pain and pressure caused by a deep abscess in the posterior spine. This procedure involves making an incision in the skin over the abscess, dissecting through the soft tissue and superficial fascia, removing necrotic tissue and pus, irrigating the area, inserting a drainage tube, and closing the incision.

2. Official Description

The official description of CPT code 22010 is: ‘Incision and drainage, open, of deep abscess (subfascial), posterior spine cervical, thoracic, or cervicothoracic.’

3. Procedure

During the procedure described by CPT 22010, the healthcare provider first prepares the patient and administers anesthesia. They then make an incision in the skin over the abscess and carefully dissect through the soft tissue and superficial fascia until they reach the deep fascia adjacent to the muscle layer. The provider removes any necrotic tissue and pus, irrigates the area, inserts a drainage tube, checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT 22010 is performed on patients who have developed a deep abscess in the posterior spine, specifically in the cervical, thoracic, or cervicothoracic region. This procedure is indicated when the abscess causes pain and pressure that requires intervention. The healthcare provider must ensure that the patient is appropriately prepped and anesthetized before performing the procedure.

5. When to use CPT code 22010

CPT code 22010 should be used when a healthcare provider performs an incision and drainage procedure on a deep abscess in the posterior spine, specifically in the cervical, thoracic, or cervicothoracic region. This code is appropriate when the procedure is performed as a standalone intervention to relieve pain and pressure caused by the abscess.

6. Documentation requirements

To support a claim for CPT 22010, the healthcare provider must document the following information:

• Patient’s diagnosis and the presence of a deep abscess in the posterior spine
• Details of the procedure, including the incision, dissection, removal of necrotic tissue and pus, irrigation, insertion of drainage tube, and closure of the incision
• Date and duration of the procedure
• Any complications or unexpected findings during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 22010, ensure that the procedure is performed on the posterior spine in the cervical, thoracic, or cervicothoracic region. It is important to follow the specific documentation requirements and guidelines provided by the payer to ensure accurate and appropriate billing.

8. Historical information

CPT 22010 was added to the Current Procedural Terminology system on January 1, 2006. Since its addition, there have been some changes in its status as an inpatient-only (IPO) procedure for Medicare. In 2017, it was added to the IPO list, but in 2021, it was removed from the IPO list. However, in 2022, it was added back to the IPO list.

9. Similar codes to CPT 22010

There are several similar codes to CPT 22010 that describe incision and drainage procedures on different regions of the spine. These codes include:

• CPT 22015: Incision and drainage, open, of deep abscess, subfascial, posterior spine, lumbar, sacral, or lumbosacral
• CPT 22005: Incision and drainage, open, of deep abscess, subfascial, posterior spine, lumbar, sacral, or lumbosacral; complicated or multiple
• CPT 22011: Incision and drainage, open, of deep abscess, subfascial, posterior spine, lumbar, sacral, or lumbosacral; complicated or multiple
• CPT 22012: Incision and drainage, open, of deep abscess, subfascial, posterior spine, lumbar, sacral, or lumbosacral; complicated or multiple
• CPT 22014: Incision and drainage, open, of deep abscess, subfascial, posterior spine, lumbar, sacral, or lumbosacral; complicated or multiple

9. Examples

1. A patient presents with a deep abscess in the cervical spine causing severe pain and pressure. The healthcare provider performs an incision and drainage procedure using CPT code 22010 to relieve the symptoms.
2. Following a spinal surgery, a patient develops a deep abscess in the thoracic spine. The healthcare provider performs an incision and drainage procedure using CPT code 22010 to address the abscess.
3. A patient with a cervicothoracic abscess requires intervention to relieve pain and pressure. The healthcare provider performs an incision and drainage procedure using CPT code 22010 to treat the abscess.
4. During a routine examination, a deep abscess is discovered in the cervical spine of a patient. The healthcare provider decides to perform an incision and drainage procedure using CPT code 22010 to alleviate the symptoms.
5. A patient with a known history of abscesses in the posterior spine presents with a new abscess in the thoracic region. The healthcare provider performs an incision and drainage procedure using CPT code 22010 to address the abscess.
6. Following a traumatic injury, a patient develops a deep abscess in the cervicothoracic spine. The healthcare provider performs an incision and drainage procedure using CPT code 22010 to treat the abscess and relieve the associated pain and pressure.