Incision and Drainage of Pilonidal Cyst Coding
The Coding Challenge
Question:
A patient is seen in the dermatologist’s office for a painful growth in the sacrococcygeal region that weeps fluid. A diagnosis of a pilonidal cyst is made, and a simple incision and drainage is performed with normal wound care. Select the appropriate procedure code.
A. 10081
B. 10060
C. 10080
D. 10120
Answer:
C. 10080
10080, Incision and drainage of pilonidal cyst; simple
The sacrococcygeal region refers to the sacrum and coccyx (tailbone). A pilonidal cyst is a skin condition that is most often found in the sacrococcygeal region. This is the cleft between the buttocks below the base of the spine.
You can learn more about pilonidal cysts and how to report them in ICD-10-CM in a separate post here.
Codes for incision and drainage (I&D) procedures are located in the Integumentary System section of the CPT coding manual, and under the subsection called Incision and Drainage Procedures on the Skin, Subcutaneous and Accessory Structures (10040-10180).
Codes specific to incision and drainage of pilonidal cysts are CPT 10080 and 10081 and are classified as simple and complicated.
Other conditions that may require an I&D include an abscess (such as a carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia), a hematoma, and wound infection.
Incision and drainage basically means that the physician incises, or opens, the lesion and allows it to drain.
Locate and Verify
In the CPT Index, look under Incision, and drainage, cyst, pilonidal cyst, 10080-10081.
In the Tabular, we can verify our correct code as:
10080, Incision and drainage of pilonidal cyst; simple
There are other search terms that can be used, such as Drainage, cyst, pilonidal, or Pilonidal cyst, incision and drainage. These terms will all take you to the same code.
Documentation
The physician should determine whether the incision and drainage is simple or complex based on the work involved and should use these terms in the documentation.
Incorrect Answers
A, B, and D are incorrect.
A. 10081 refers to Incision and drainage of pilonidal cyst; complicated.
B. 10060 refers to Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single.
D. 10120 refers to Incision and removal of foreign body, subcutaneous tissues; simple.
Incision and Drainage Procedure
A pilonidal cyst is usually treated initially in the physician’s office. If there is an infection (abscess), a procedure called an incision and drainage (I&D) is performed. Antibiotics will not heal the cyst.
According to Medicinenet.com, an I&D involves:
- Cleansing the skin and injecting it with a local or general anesthetic to numb the area.
- Making a small incision to drain the pus and debris from the cyst cavity.
- In a simple case, local wound care is provided, and typically the area is left open to heal. In a complicated case, a drain may be placed, or the area may be packed with gauze.
If the cyst comes back, which is not unusual, a more extensive surgical procedure, called a pilonidal cystectomy, may be needed to remove the entire cyst and tissues around it.
When reporting for a pilonidal cystectomy in ICD-10-CM, excision codes 11770, 11771, and 11772 are used to describe simple, extensive, and complicated excision.
Puncture Aspiration Differs From an I&D
Puncture Aspirations (10160) are also located in the same category as codes for Incision and drainage of pilonidal cyst. An aspiration and an I&D both involve draining fluid. However, aspiration is different in that it involves the insertion of a needle into a lesion to aspirate, or withdraw, fluid from the lesion.
There is no incising (cutting) of the skin with an aspiration.
Related
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