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buttock abscess

ggparker14

True Blue
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Can someone help me with CPT for this procedure? Is this buttock abscess the same as a pilondial cyst?

Note reads: the skin overlying the abscess was cleaned with Betadine x 3, anesthetized with 1% 3 cc xylocaine with epinephrine. The abscess was incised with a 15 blade and was productive of purulent fluid. Approximately 2 cc of ***** discharge was expressed from the abscess. A wound culture was done. The wound was then explored sterilely with a hemostat. Idoform gauze was used to pack the wound and for drainage. EPB was minimal. A dressing was applied.

thanks for any help.
 

DeeCPC

Guru
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126
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Can someone help me with CPT for this procedure? Is this buttock abscess the same as a pilondial cyst?

Note reads: the skin overlying the abscess was cleaned with Betadine x 3, anesthetized with 1% 3 cc xylocaine with epinephrine. The abscess was incised with a 15 blade and was productive of purulent fluid. Approximately 2 cc of ***** discharge was expressed from the abscess. A wound culture was done. The wound was then explored sterilely with a hemostat. Idoform gauze was used to pack the wound and for drainage. EPB was minimal. A dressing was applied.

thanks for any help.
No, a buttock abcess is not necessarily a pilonidal cyst. The provider does not call the cyst a pilonidal cyst. They do not describe a typical pilonidal cyst. I think it is important to know what a pilonidal cyst is to know if it is possibly what was treated. A pilonidal cyst is usually at the tailbone and is filled with hair and skin debris.
 

keke74

Guru
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Hello, the documentation should state whether or not its a Pilonidal abscess or buttock abscess. Since the wound was packed with gauze, I would use 10061.
 

eadun2000

Expert
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487
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Hello, the documentation should state whether or not its a Pilonidal abscess or buttock abscess. Since the wound was packed with gauze, I would use 10061.
absolutely agree. When an abscess is packed with gauze, it is complicated. Same as if you have multiple abscesses. The correct CPT code is 10061.
 

DCoburn

Contributor
Messages
11
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Buttock abscess

I also agree with KeKe 74. The documentation states "incision into the skin." Buttock is the skin location where the abscess is located. I also agree on the complication code 10061 due to the fact that the abscess was explored and packed.

DC
 
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