Revenue Cycle Insider

Question: A 54-year-old patient presents to the emergency department (ED) with a painful, red, and swollen “boil” at the base of their spine near the buttocks. The patient has a history of venous thrombosis. During their examination, the physician diagnoses the patient with a pilonidal cyst without abscess and decides to perform an incision and drainage (I&D). The physician uses lidocaine to numb the area and drains and packs the cyst. A swab of the wound drainage is sent to the lab for culture, as the physician suspects Methicillin-resistant Staphylococcus aureus (MRSA). The patient is advised on wound care and hygiene and given instructions for follow-up care. As the patient has a history of venous thrombosis, the physician places them on preventive antibiotic therapy. Notes indicate that the physician performed moderate medical decision making (MDM) during the E/M.

How should I report this encounter?

RCI Subscriber

Answer: You’ll report a trio of CPT^® codes for this encounter, a pair of ICD-10-CM codes, and one modifier. On your claim, report:

• 10080 (Incision and drainage of pilonidal cyst; simple) for the I&D
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making) for the E/M service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99284 to indicate that the E/M and the I&D were significant, separately identifiable services
• 87081 (Culture, presumptive, pathogenic organisms, screening only) for the culture
• L05.91 (Pilonidal cyst without abscess) appended to 10080, 99284, and 87081 to represent the patient’s cyst
• Z86.718 (Personal history of other venous thrombosis and embolism) appended to 10080, 99284, and 87081 to represent the patient’s history of venous thrombosis

Warning: Avoid the temptation to use the standard simple I&D code 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single). Since 10080 specifies pilonidal cyst, it’s the code you’ll use in this situation.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC