General Surgery Coding Alert

Surgeon’s level of effort counts.

With few hard and fast rules to focus pilonidal disease reporting for cases your surgeon encounters, we have some tips that should help you do the job right.

Let our experts guide your diagnosis and procedure coding with specific terminology you should look for in your surgeon’s op report

Master the Terminology

The surgeon will typically identify the condition as a pilonidal sinus, dimple, or cyst. All three terms refer to an abnormality that typically occurs near the tailbone (sacrum or coccyx) at the top of the buttocks’ cleft.

Synonyms: You might also see the condition described as pilonidal disease, sacrococcygeal or coccygeal sinus, or postanal dimple.

Pilonidal disease is more common in adolescent or older males, especially in sedentary individuals. The cause is hair puncturing the skin and becoming embedded, which often becomes infected and painful. The surgeon may note hair, skin, debris, pus, and blood within the abnormality.

The following glossary defines certain terms that you may see in the op report:

• Dimple – Indentation or fold in the skin.
• Sinus – Abnormal channel from an opening in the body surface.
• Fistula – Abnormal channel that connects from an opening in the body surface to an internal organ or cavity.
• Cyst – Sac-like pocket containing fluid, pus, or other substances.
• Abscess – Collection of pus due to infection that often causes painful swelling and redness.

Understanding these terms will help you focus your diagnosis and procedure coding.

Caution: Not every dimple, opening or abscess in the sacral regions is pilonidal disease. Clinicians may identify similar conditions, but details will differ that aid in differential diagnosis.

For instance, a congenital sacral dimple or parasacral dimple occurs in newborns at the same anatomic site but does not involve embedded hair or infection. Clinicians may also identify an anal fistula with similar characteristics, except the tract may originate in a different location and connects to the anal wall.

Clarify Diagnosis Code

Using the following steps plus your knowledge of all the terms in the previous section, you can glean details from the op report to zero in on the proper diagnosis code:

Step 1: Make sure the surgical site corresponds to pilonidal disease. Although similar cysts containing hair may occur in other anatomic sites, such as between fingers (an occupational hazard associated with a profession such as hair stylist), these are uncommon. Pilonidal disease almost always occurs in the sacrococcygeal region.

Step 2: Look for documentation of abscess, either by the surgeon using the term in the op note or at least describing inflammation and a collection of pus. Whether the case involves an abscess leads to two distinct code families:

• L05.9- (Pilonidal cyst and sinus without abscess)
• L05.0- (Pilonidal cyst and sinus with abscess)

Step 3: Determine if the surgeon documents the abnormality as a cyst or sinus. That distinction points you to one of the following specific codes:

• L05.01 (Pilonidal cyst with abscess)
• L05.02 (Pilonidal sinus with abscess)
• L05.91 (Pilonidal cyst without abscess)
• L05.92 (Pilonidal sinus without abscess)

Link Complexity to Procedure Code

Surgeons typically treat pilonidal cysts or sinuses by performing either incision and drainage (I&D) or excision.

Key: You have to get the diagnosis code right if you want to report to the correct procedure code. That’s because CPT^® provides specific codes for pilonidal cyst surgery that are distinct from more general codes for I&D, such as 10060-10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia) …) or excision, such as 11400-11406 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs …).

Once you know you’re dealing with pilonidal disease surgery, you then need to determine if the surgeon documents an I&D or excision procedure. That distinction leads to the following two different code families:

• 10080 (Incision and drainage of pilonidal cyst; simple)
• 10081 (… complicated)
• 11770 (Excision of pilonidal cyst or sinus; simple)
• 11771 (…extensive)
• 11772 (…complicated)

Complexity: Deciding where a pilonidal cyst I&D or excision procedure falls on the scale from “simple” to “complicated” is not simple.

That’s because “CPT^® does not define ‘simple’ or ‘complicated’ in this context,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Direction: Per a CPT^® Assistant Q&A (2006, Volume 16, Issue 12), “the choice of [pilonidal cyst I&D] code is at the physician’s discretion, based on the level of difficulty involved in the incision and drainage procedure.”

Do this: Encourage surgeons to specifically designate the level of complexity in these cases using the term “simple,” “extensive,” or “complicated.”

“Without those terms, coders may want to use the details of the op note to assign a level and/or contact the surgeon for clarification,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, California.

Code Most Extensive Procedure

I&D is often the first treatment of choice for pilonidal disease, but recurring cysts, or conditions such as multiple sinuses may result in the surgeon choosing excision.

Sometimes the surgeon may begin the procedure as an I&D but convert to an excision during the operative session based on conditions at the site.

Don’t double dip: If the surgeon performs an I&D and excision at the same session and same anatomic site, you won’t be able to report both procedures per AHA HCPCS Coding Clinic (Volume 9, Issue 14). The article states, “a physician excising pilonidal cysts and/or sinuses (CPT^® codes 11770-11772) may incise and drain one or more of the cysts. It is inappropriate to report CPT^® code 10080 or 10081 separately for the incision and drainage of the pilonidal cyst(s).” This guidance is reinforced by National Correct Coding Initiative (NCCI) edits that bundle I&D (10080 and 10081) into excision (11770-11772).