Primary Care Coding Alert

Question: An established patient reports to the FP with a tender mass at the apex of his gluteal cleft. He says he began feeling it four days ago, and the pain has increased every day since then; it is especially painful when he tries to sit down. During a level-four E/M, the physician finds a tender, egg-sized mass that has a small opening with a hair at its center. The FP preps the patient, and makes a stab incision to the cyst, which yields 15 ml of pus. He then irrigates the cavity, leaves the wound open, and instructs the patient to schedule a follow-up visit. Is this a simple or complicated incision and drainage (I&D)?

Utah Subscriber

Answer: This is neither a simple or complicated I&D; it is an I&D of a simple pilonidal cyst, which means coding will change. On the claim, report the following:

" 10080 (Incision and drainage of pilonidal cyst;simple) for the I&D

" 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M

" modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99214 to show that the E/M and I&D were separate services

" 685.0 (Pilonidal cyst; with abscess) linked to 10080 and 99214 to represent the patients cyst.

Pilonidal profile: While you will code most of your FPs I&D procedures with 10060 or 10061, youll also need to know what constitutes a pilonidal cyst, which forms at the bottom of the coccyx. Usually, patients with this injury will present with pain just above the central buttock crease with swelling and fever.