Wiki Pilonidal Cyst

[AgnieszkaLakritz]

Hello fellow coders,

I have two similar cases for Pilonidal cyst excision.Looking for you opinion on coding these two. I have idea what codes to use, however I was asked to code it in certain way which I am not comfortable with. I am looking for opinions to either support my way of coding of the other coder. I'd like to add this is done by the same surgeon.
1.
PREOPERATIVE DIAGNOSIS: Pilonidal cyst.

POSTOPERATIVE DIAGNOSIS: Pilonidal cyst.

OPERATION: Excision of pilonidal cyst with complex closure.

ANESTHESIA: MAC.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a 21-year-old female presenting with a pilonidal
cyst of one-year. She was seen in clinic and the benefits and risks of the procedure were
described and she agreed to go ahead with the procedure. Consent was obtained in clinic.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the
operating room table in the prone position. MAC anesthesia was induced. She was prepped and
draped in the usual sterile fashion. A time-out was performed confirming the correct
patient, procedure and location. Lines were marked with a marking pen to incorporate all
the areas of pilonidal cyst and a draining sinus superiorly.

Local anesthetic was injected. An elliptical incision incorporating a sinus tract was made.
Cautery was used for dissection and hemostasis. The dissection carried through to remove
the area of the pilonidal cyst. A flap was created on the contralateral side with cutaneous
and subcutaneous fatty tissue. The flap was advanced to the contralateral side. The tissue
was fixed on the contralateral side using 4.0 Monocryl.

The subcutaneous tissue was closed in layers with the 4.0 Monocryl. Deep dermals were
closed as well as subcuticular tissue was closed with 4.0 Monocryl. The incision was closed
with Dermabond and dressed.
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2.
PROCEDURE: Pilonidal cyst excision.

ANESTHESIA: MAC.

PREOPERATIVE DIAGNOSIS: Chronic pilonidal cyst.

POSTOPERATIVE DIAGNOSIS: Chronic pilonidal cyst.

PROCEDURE: Excision and primary closure of pilonidal cyst.

INDICATIONS: This is a 33-year-old male who presents with a chronic pilonidal cyst of one
year requiring incision and drainage related to the midline and currently quiescent. The
patient elected to undergo excision and primary closure for management of his pilonidal
cyst. Risks and benefits were explained to the patient and he agreed to go ahead with the
procedure. Consent was obtained in clinic.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and MAC anesthesia
was induced. The patient was placed in the prone position. The buttocks were gently spread
with tape. The presacral region was prepped and draped in usual sterile fashion and time
out was performed confirming correct patient, procedure and location. An opening was
evident on the midline with a tract likely inserted. An elliptical incision was made around
the opening over the entire tract and continued off the midline. The incision was deepened
through subcutaneous tissue using electrocautery and continued down until fascia and normal
tissue deep to the tract was encountered. The pilonidal sinus tract was thus excised
cleanly in its entirety. Hemostasis was achieved with electrocautery. Flaps were developed
until the skin and subcutaneous tissue could be approximated off midline without tension.
The incision was closed with interrupted Monocryl sutures in multiple layers so as to
completely close the dead space. Running subcuticular sutures closed the skin and skin was
further closed with Dermabond. The patient tolerated the procedure well and was taken to
the postanesthesia care unit in stable condition. Estimated blood loss was 10 mL.

 

[Orthocoderpgu]

I work in orthopedics. Cysts and masses are frequently removed. The codes depend on the specific location. Frequently the excised tissue is sent for pathology which can change the coding since the code to remove a mass and cyst are different. The first surgery the surgeon does not state what tissue the actual cyst was removed from. There is no path report. The surgeon did not perform complex closure which usually involves more than layered closing with retention sutures and extensive undermining. Neither is documented. Seems to have done more of a adjacent tissue transfer. I'm thinking of a code in the 14000 section.

Second surgery the surgeon removed a sinus track with no cyst mentioned.

 

[fwnewbie]

Pilonidal cysts are inherently located in the sacral area so I can see why the provider didn't make any effort to locate the surgical area. Also, I don't believe they are usually sent for pathology because they are pretty visually distinct and not prone to malignancy (the same with sebaceous cysts as far as distinct without pathology).
I think the repairs are accomplished through undermining of adjacent tissue rather than creating an advancement flap but looking at the description of Intermediate repair for the closure you still need the length of the defect in cms to code any of the repairs. The first case was only down to the subq tissue and the second was deeper and down to the fascia so the second was more work and both had a layered closure.
My bottom line is: without a measurement of the length of these incisions and without further info on what constitutes "simple", "extensive", or "complicated" in an excision of pilonidal cyst, I have no answer I'm comfortable with either.

 

[AgnieszkaLakritz]

Hello to my people who replied,

thank you, here is the path report to the 2nd case.
my biggest concern is if the second case can be coded 11772 and 14000 as i was advised to do. I am not comfortable with this codes selection that's why I asked for opinion.

MICROSCOPIC DIAGNOSIS:
Skin, Pilonidal Cyst, Excision:
Consistent with pilonidal cyst, (see note)

Note: The hematoxylin and eosin stained sections show skin and subcutaneous
adipose tissue with acute, chronic, and granulomatous inflammation with foreign
body giant cell reaction, hair shafts, granulation tissue, and fibrosis,
consistent with pilonidal cyst.


SPECIMEN:
Pilonidal cyst

CLINICAL DIAGNOSIS:
Pilonidal cyst

POST-OPERATIVE DIAGNOSIS:
Same as clinical impression

GROSS:
The specimen is received in formalin labeled "pilonidal cyst" and consists of
a 5.8 x 2.1 x 1.0 cm skin ellipse without orientation. The skin surface is
gray-brown and wrinkled. The specimen is serially section to reveal
tan-yellow unremarkable subcutaneous tissue. Also identified within the same
container is a 1.7 x 1.1 x 1.0 cm red-brown congested portion of soft tissue.
The specimen is bisected to reveal an infected sinus tract. Representative
sections are submitted in two blocks labeled 1-2. (RR)

 

[fwnewbie]

I agree with you - why is this procedure considered "complex"? At best all that was done was undermining the subq tissue to release enough skin to cover the wound.
An advancement flap is fashioned by making strategic incisions in the skin and realigning it to cover the original defect and the secondary defect and this wasn't done.
AT most I could see 11771 to account for the depth and an intermediate repair code, but you still need the linear length of the incision in order to select a code.
PS I worked for a Plastic Surgeon's group for a few years and saw a lot of this stuff done and they were very meticulous in their documentation and measurements.

 

[Shweta]

Hi,
For report# 1, I will code 11772 and 14000 as it documents, "a flap was created on the contra-lateral side with cutaneous and subcutaneous fatty tissue. The flap was advanced to the contra-lateral side."
For report# 2, I agree with you there is not sufficient documentation for adjacent tissue transfer. The flaps were approximated in mid-line and layered closure was performed. There is no documentation for repair by adjacent tissue transfer or rearrangement.
I hope this helps

 

[fwnewbie]

#1 I don't see the first case as complicated at all for a pilonidal cyst - no drain or stay sutures needed/used and the "flap" was not created by a separate skin incision, it was just undermining the existing tissue and bringing the edges together. Without the length of the wound documented, you can't even code the repair as Intermediate because it was layered and there was limited undermining. So my thought is 11770 only.
#2 Was deeper so 11771 but same goes for the Intermediate repair - he's got to document the length of the elliptical incision, not the length of the specimen, to code the repair.