Abscess Incision and Drainage
Incision and drainage of [location] abscess
Cutaneous abscess of the [location] [with / without] surrounding cellulitis, present for [X] days, requiring incision and drainage[ in a patient with [recurrent MRSA infection / diabetes / immunosuppression]].
[[Verbal / Written] informed consent was obtained after discussion of risks, benefits, and alternatives].
[***, MD/DO]
Local: [X] mL 1% lidocaine without epinephrine [field block / ring block][, with [IV ketamine sedation / IV morphine analgesia] as an adjunct]
A [X × X] cm [fluctuant / tender / erythematous] abscess of the [location] was identified. [X] mL of [purulent / seropurulent / bloody-purulent] material was drained. The cavity measured [X × X × X] cm, and [loculations were present / no loculations were present]. There was no fascial involvement, crepitus, or tracking. No foreign body was identified.
[A time-out was completed confirming the patient, procedure, and site.] The patient was positioned to provide access to the [location]. The overlying skin was prepped with [povidone-iodine / chlorhexidine] and draped in sterile fashion. The skin and surrounding subcutaneous tissue were infiltrated with [X] mL of 1% lidocaine as a [field block / ring block]. Adequate anesthesia was confirmed by loss of sharp sensation.
A [linear / cruciate / elliptical] incision was made with a [11-blade / 15-blade] scalpel over the point of maximal fluctuance and extended to the full length of the abscess cavity. Purulent material was expressed manually.
The cavity was explored with [a gloved finger / a curved hemostat] to break up loculations and confirm the extent of the cavity. [The cavity walls were curetted to disrupt the abscess wall.] The cavity was irrigated with normal saline until the return was clear.
[The cavity was loosely packed with [iodoform / plain] gauze to maintain drainage / The wound was left open without packing]. A dry dressing was applied.
Minimal
[Purulent material sent for aerobic and anaerobic culture / None]
None
Wound care instructions were given for [daily dressing changes / daily wet-to-dry dressing changes]. Follow-up is planned in [2-3] days for [packing removal / a wound check]. [[Antibiotic] was prescribed for [X] days.] Return precautions for signs of worsening infection were reviewed.
Epic SmartPhrase Version
PROCEDURE: Incision and drainage of *** abscess
INDICATION: Cutaneous abscess of the *** [with / without] surrounding cellulitis, present for *** days, requiring incision and drainage.
CONSENT: [Verbal / Written] consent obtained after discussion of risks, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine [field block / ring block]
FINDINGS: *** × *** cm fluctuant abscess. *** mL *** material drained. Cavity *** × *** × *** cm, loculations ***. No fascial involvement, crepitus, or tracking. No foreign body.
PROCEDURE DETAILS:
[Time-out completed.] Patient positioned. Site prepped and draped in sterile fashion. *** mL 1% lidocaine [field block / ring block], adequate anesthesia confirmed. [11 / 15]-blade incision over point of maximal fluctuance, extended to full cavity length. Purulent material expressed. Cavity explored, loculations broken. Irrigated with normal saline until clear. [Loosely packed with [iodoform / plain] gauze / Left open without packing]. Dry dressing applied.
EBL: Minimal
SPECIMENS: [Aerobic and anaerobic wound culture / None]
COMPLICATIONS: None
POST-PROCEDURE PLAN: Wound care instructions given. Follow-up in *** days for [packing removal / wound check]. [*** prescribed for *** days.] Return precautions reviewed.
Signed: .ME, .MYDEGREE
.TODAYVariants
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. Fistula probing was deferred. The patient was counseled about the risk of an underlying fistula-in-ano or a persistent draining sinus requiring further evaluation. Surgery follow-up was arranged.
Loop Drain Placement (Large or Complex Abscess)
Given the large cavity size and risk of premature closure with packing, a [vessel loop / Penrose drain] was placed through the cavity as a loop drain. A second small stab incision was made on the opposite side of the abscess, and the drain was threaded through the cavity and tied loosely externally. The loop drain will be removed at follow-up once drainage has ceased.
Charting Tips
- Infiltrate local anesthetic around the abscess rather than directly into the infected cavity. The acidic environment of infected tissue impairs anesthetic effect.
- A loop drain maintains drainage while the cavity closes from the inside out. Loop drainage has been reported as equivalent to packing with less patient discomfort and fewer return visits (Tsoraides 2010, Kessler 2012).
- 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: IDSA guidelines do not require culture for uncomplicated community-acquired abscesses in immunocompetent patients. Cultures are indicated in:
- Immunocompromised patients
- Failure of prior antibiotic therapy
- Recurrent infections
- Suspected MRSA clustering or outbreak
- Severe/systemic infection
Document your decision and the rationale.
Documentation & Reimbursement Considerations
- Primary service: Report Abscess Incision and Drainage as the primary service when it is the definitive operation performed.
- Report the simple incision and drainage service (1.19 wRVU, 10-day global) for an uncomplicated superficial abscess drained in a single location.
- Report the complicated incision and drainage service (2.39 wRVU, 10-day global) 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 ultrasound is used to localize a deep abscess before incision, imaging guidance (0.65 wRVU) may be reported separately only with documented real-time imaging and a permanent image record.
- Pilonidal abscesses (1.19 wRVU simple, 2.44 wRVU complicated) and anorectal abscesses (ischiorectal or perirectal 5.24 wRVU, intramural or submucous 6.21 wRVU, 90-day global) have their own drainage services. Do not report them with the skin abscess incision and drainage services.