Internal Medicine Coding Alert

Question: The PA found a cyst on a patient's labia during her pelvic screening (the patient said she didn't know it was there prior to the exam). Because the cyst was already partially open, the PA only needed to express it until the contents came out. Can we code anything for this in addition to the exam?

Indiana Subscriber

Answer: No, you shouldn't charge for the expression since the cyst was already open.

CPT® does not have a code for manually expressing a cyst. If the PA had incised the cyst in order to drain the contents, you could report an incision and drainage code, such as 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single). As it is, I&D codes don't apply because no incision was made. Simply include the service as part of the office visit.