Urology Coding Alert

Question: One of the doctors I code for did an excision of a groin sinus tract, and the diagnosis was "infected groin sinus." I have looked everywhere in the CPT and ICD-9 books to find the codes and I am at a loss. What do I report for the procedure and diagnosis?

South Carolina Subscriber

Answer: You should choose the appropriate procedure code from the 11040-11044 range (such as 11043, Debridement; skin, subcutaneous tissue, and muscle), depending on how deep the sinus tract went, and how deep the surgeon had to go for the complete excision of the sinus tract.

The most likely diagnosis code for this procedure is 686.9 (Unspecified local infection of skin and subcutaneous tissue), which should also prove the medical necessity for the procedure.