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 [...]