Recognize What Separates Pilonidal, Standard Cysts or Risk Rejection

Procedure similar to standard I&D, but codes differ

If you report 10060 or 10061 when your ED physician performs I&D on a pilonidal cyst, you’ll trigger a denial for not using the procedure’s specific codes.

While you will code most of your ED physician’s incision and drainage (I&D) procedures with 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) or 10061 (… complicated or multiple), you’ll also need to know what constitutes a pilonidal cyst.

A pilonidal cyst forms at the bottom of the coccyx if it gets infected and becomes an abscess, antibiotics alone will not cure the problem. Usually, patients with this injury will present with pain just above the central buttock crease with swelling, and fever.

Consider the following example from Robert LaFleur, MD, FACEP, of Medical Management Specialists in Grand Rapids, Mich.

A patient reports to the ED with an enlarging, tender mass at the apex of his gluteal cleft. He says it started four days ago, and the pain is nearly unbearable now – especially when he tries to sit down. During a level-four E/M, the physician finds a tender, egg-sized mass that has a small opening with a hair at its center. The ED physician preps the patient, and makes a stab incision to the cyst, which yields 15 ml of pus. (He then irrigates the cavity, leaves the wound open, and instructs the patient to follow up with his primary care physician.)

Solution: This is an example of a pilonidal cyst. On the claim, report the following:

• 10080 (Incision and drainage of pilonidal cyst; simple) for the I&D
• modifier 54 (Surgical care only) linked to 10080 to show that you are not providing follow-up care for the patient
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M and I&D were separate services
• 685.0 (Pilonidal cyst; with abscess) linked to 10080 and 99284 to represent the patient’s cyst.