Pediatric Coding Alert

Question: Our provider’s notes say he “removed a 2.5 x 2 cm sebaceous cyst by incision” from a patient. However, the procedure was written as “2 mm vertical incision made in the middle of nodule. Removal of large amount of sebaceous material.” He then cleaned the wound and placed a single 4-0 Ethilon suture. The patient is to follow up for suture removal in 1 week. Should I report this as incision and drainage (I&D) or as cyst removal?

AAPC Forum Participant

Answer: If you interpret the procedure as a removal, it’s easy to see why you might consider reporting a code such as 11403 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm). Based on how the procedure is written though, this was an I&D procedure that calls for 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single).

Here’s why. Even though the provider said that he “removed” the cyst, he also said this was done “by incision.” An excision means to cut something out. That’s not what happened during this procedure. The provider made a 2 mm incision and removed sebaceous material. Generally, if the cyst is removed or excised, the note should say that an incision was made around the area and incised down to the subcutaneous tissue, or it should describe an incision the length of cyst and the cyst sac is peeled out from underneath the skin.