CPT Code 10180: Incision and Drainage, Complex Postoperative Wound Infection

What is complex incision and drainage of postoperative wound?

CPT code 10180 describes complex incision and drainage procedures for a postoperative wound infection incision involving skin, subcutaneous tissue, and often deeper accessory structures. Unlike simple I&D codes (10060–10061), this service is performed in an operating room with sterile technique, advanced surgical instruments, and may include:

• Removal of necrotic or foreign body material
• Placement of drains or wound‑VAC systems
• Extensive debridement of fluid collection or abscess cavities
• Repeat bedside or intra‑op drainage services to promote healing

Common indications include dehisced incisions after abdominal surgery, infected pilonidal cyst excisions, or orthopedic hardware infections causing severe pain and drainage.

CPT code 10180 documentation requirements

To support medical necessity, chart the following:

• Confirmed postoperative wound infection or abscess (culture results if available)
• Exact surgical site and depth (e.g., fascia, muscle, or subcutaneous and accessory structures)
• Step‑by‑step incision and drainage technique: length of incision, amount of drainage, debridement, and packing
• Type of anesthesia (local vs. general) and any imaging guidance
• Post‑procedure plan: antibiotics, packing changes, follow‑up physical therapy.

If mobility is affected, commercial payers, chart the following:

• Confirmed postoperative wound infection or abscess (culture results if available)
• Exact surgical site and depth (e.g., fascia, muscle, or subcutaneous and accessory structures)
• Step‑by‑step incision and drainage technique: length of incision, amount of drainage, debridement, and packing
• Type of anesthesia (local vs. general) and any imaging guidance
• Post‑procedure plan: antibiotics, packing changes, follow‑up physical therapy if mobility is affected

Documentation is completed thoroughly to support accurate billing, as typically reviewed by Medicare Administrative Contractors or other payers during claims processing.

CPT code 10180 billing guidelines

To ensure proper reimbursement and coding accuracy, follow these billing practices when reporting complex incision and drainage procedures for postoperative wound infections:

• Report once per site, per session. If multiple wounds on different anatomic regions require treatment, list 10180 for each site with modifier 59.
• Modifier 78: Use when returning to the OR during a global period for a related infection.
• Avoid unbundling: do not report 10061 or superficial debridement codes for the same infected wound on the same date.
• Medicare beneficiaries: check local MAC policy for global day counts and documentation triggers.
• Supplies (e.g., drains, wound‑VAC kits) are typically bundled; bill separately only if your payer allows.

Other relevant CPT codes

• 0060–10061 – Simple/complicated I&D of skin abscess (non‑post‑op)
• 11042–11047 – Debridement extending into muscle, fascia, or bone
• 12021 – Packing removal during follow‑up visit (if separate session)