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pilonidal excision

  1. #1
    Default pilonidal excision
    Exam Training Packages
    Hello coders,

    Can you please help me to code the below op report...

    "piloonidal area exposre as pt prone ans identification of sinus opening and introduction of canula inside and injection of methylene blue inside for localization after that cut the edge and diathermy cut follow up the fistulous track up to its base with complete hemostasis and diathermy followed by pack and dressing after lay open technique"

    11770 or 11771 or 11772

    Thanks in advance...

  2. #2
    Springfield Mo AAPC
    I would probably code 11771, and ask the Dr. to be more specific with description, to the base?? But it does sound like he went pretty deep, but based on your info the 11771

  3. #3
    Milwaukee WI
    Default 11770
    I would code this (terrible) documentation as 11770

    From Encoder pro

    A pilonidal cyst or sinus is entrapped epithelial tissue located in the sacrococcygeal region above the buttocks. These lesions are usually associated with ingrown hair. A sinus cavity is present and may have a fluid-producing cystic lining. With a small or simple sinus in 11770, the physician uses a scalpel to completely excise the involved tissue. The wound is sutured in a single layer.
    In 11771, the extensive sinus is superficial to the underlying fascia but has subcutaneous extensions. The physician uses a scalpel to completely excise the lesion. The wound may be sutured in several layers.
    In 11772, the sinus is more complicated and has many subcutaneous extensions. The physician uses a scalpel to completely excise the involved tissue. Local soft tissue flaps (i.e., Z-plasty) may be required for closure of a large defect or the wound may be left open to heal by granulation.

    I don't see any evidence in this documentation to support the higher level codes of 11771 or 11772.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Default pilonidal excision
    Thanks for you comments....The wound is not closed in layers... and it also states "diathermy cut follow up the fistulous track up to its base"

    Can we take this as granted for 11772 since he has also documented "dresssing after lay open technique"......

    Your comments greatly appreciated...

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