Primary Care Coding Alert

Question: Documentation reads, "The cyst was excised after performing a central incision directly on the cyst. All the material was expressed, then cyst capsule was removed completely and excised completely. Packing was performed." Should I code the procedure as an I&D or an excision? Codify Member Answer: You should look at the pathology report and any further excision description to reach the correct code set. "Excision is defined as full thickness [through the dermis] removal of a lesion ...," according to CPT's Excision-Benign Lesions guidelines. The documentation you provided does not indicate what tissue levels the excision involved. A cyst can be epidermal or sebaceous (706.2). A lesion that is removed from the epidermis (top skin layer) does not meet CPT's excision definition. The sebaceous gland extends through the dermis. Excision that deep would qualify for an excision code. An excision code (such as 11400, Excision, benign lesion including margins, [...]