Pediatric Coding Alert

Question: Can you help me with CPT® code assignment for this procedure? The chart note reads: Exam reveals an abscess on the buttocks. The skin overlying the abscess was cleaned with Betadine x 3, anesthetized with 1% 3 cc xylocaine with epinephrine. The abscess was incised with a 15 blade and was productive of purulent fluid. Approximately 2 cc of pus was expressed from the abscess. A wound culture was done. The wound was then explored sterilely with a hemostat. Idoform gauze was used to pack the wound and for drainage. A dressing was applied." Is this buttock abscess the same as a pilonidal cyst?

Texas Subscriber

Answer: Pilonidal actually means "nest of hair" in Latin. These cysts are typically found in the upper cleft of the buttocks in the midline and originate from an embryonic remnant of tissue that becomes secondarily infected, sometimes starting from an ingrown hair. Treatment may include antibiotic therapy, hot compresses and application of depilatory creams. In the more severe cases, the cyst may need to be lanced or surgically excised. Post-surgical wound packing may be necessary, and packing typically must be replaced twice daily until healed.

If the chart notes specifically state "pilonidal cyst," or provide a detailed location to more clearly make that assumption, you can report code 10080 (Incision and drainage of pilonidal cyst; simple) or 10081 (Incision and drainage of pilonidal cyst; complicated). Whether you choose 10080 or 10081 depends solely on the physician's opinion. According to the Dec. 2006 CPT Assistant, "the choice of code is at the physician's discretion, based on the level of difficulty involved in the incision and drainage procedure."

Otherwise, you should report CPT® code 10061 (Incision and drainage of abscess [e.g. carbuncle, supportive hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, paronychia]; complicated or multiple), because of the packing needed.