ED Coding and Reimbursement Alert

Question: Encounter notes indicate that the physician performed an ED evaluation and management (E/M) service for a patient that included moderate-level medical decision making (MDM). The physician diagnosed ‘pilonidal cyst’ and performed an incision and drainage (I&D) on the cyst: the physician just made a single small incision and drained the cyst without complication. How should I code this encounter? I was thinking 10060 along with the ED E/M.

AAPC Forum Subscriber

Answer: You’ll code an I&D and an ED E/M — but don’t report 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) for the cyst I&D.

Why? Pilonidal cyst I&D has its own CPT codes. On your claim, report:

• 10080 (Incision and drainage of pilonidal cyst; simple) for the I&D
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99284 to show that the E/M led to the decision to perform the I&D

Dx coding: You’re going to need some more information in order to choose the correct ICD-10 code for this patient. Go back and check the notes for evidence of abscess. Then, choose one of the following codes to append to 10080 and 99284:

• L05.01 (Pilonidal cyst with abscess)
• L05.91 (Pilonidal cyst without abscess)

Also: Be sure not to confuse pilonidal cyst with pilonidal sinus. A pilonidal cyst is a fluid-filled sac that forms in the skin near the tailbone. It usually occurs as a result of a hair follicle becoming infected or irritated. The cyst can be painful, swollen, and may have a pus-filled abscess.

A pilonidal sinus is a small tunnel or tract that forms under the skin near the tailbone. It is often connected to a pilonidal cyst and can develop as a result of a chronic infection or inflammation. The sinus may have one or more openings on the skin’s surface, which can leak fluid or pus. It can cause pain, swelling, and recurrent infections.

You’ll report pilonidal sinus with one of the following codes:

• L05.02 (Pilonidal sinus with abscess)
• L05.92 (Pilonidal sinus without abscess).