General Surgery Coding Alert

Question: Prior to excision, the surgeon had to incise and drain a pilonidal cyst. May we report the I&D separately, or is it included in the excision?

Arizona Subscriber

Answer: No, you cannot report the incision and drainage separately.

CMS guidelines set forth in the national Correct Coding Initiative (CCI) state, "In cases where, in the course of an excision of a lesion, an area of involvement is identified which requires drainage, either as a part of the procedure or to gain access to the area of interest, coding/billing for incision and drainage of this fluid collection would be inappropriate if the excision or other procedure is performed in the same session."

An exception could occur if the I&D and excision occur at different sessions. For example, if the surgeon encounters extensive cellulitis around the cyst, which prevents excision, he may perform I&D (10080-10081, Incision and drainage of pilonidal cyst -). After several days of antibiotic therapy, the surgeon may complete the excision (11770-11772, Excision of pilonidal cyst or sinus ...), which you would report with modifier 78 (Return to the operating room for a related procedure during the postoperative period), according to CCI guidelines.

Remember, however, that medical necessity, rather than coding opportunism, should drive treatment. If the surgeon can reasonably perform the I&D and excision during the same session, he should do so, and you would report the excision only.