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Wiki buttock abscess

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ggparker14

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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.
 
rhblevins61@yahoo.com said:
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.
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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.
 
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.
 
keke74 said:
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.
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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.
 
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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