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Code This!

Scenario Week of May 06, 2011:
View Current Scenario

Indications:
The patient is a 58-year-old female with a pilonidal cyst, who presented at this time for excision.

Informed Consent:
The risks and benefits of the procedure were explained to the patient. The patient elected to proceed with the procedure.

Approach and Surgical Procedure:
The patient was brought to the operating room and placed supine on the operating table, where general endotracheal anesthesia was induced. The patient was then placed in the prone position, and padding was placed. The buttocks were taped so that exposure to the pilonidal cyst in the midline was obtained. The area of the pilonidal cyst was identified. The 10-blade scalpel was then used to make an elliptical incision to excise the area of the pilonidal cyst. This was carried down to just above the rectum and anus, at the sacral level. A large portion of the involved areas, as well as extra subcutaneous tissue was extensively removed.

Hemostasis was achieved with electrocautery and the area was copiously irrigated with saline. No further disease was noted.

At this time the wound was closed in layers using interrupted 3-0 vicryl sutures. Care was taken so that no cavities were left. The dermis was then reapproximated with 4-0 vicryl sutures and then 3-0 chromic sutures in a horizontal mattress fashion were used to evert the skin edges. The area was then cleaned and dried. The patient was awakened from anesthesia, extubated, and taken to recovery in stable condition. She tolerated the procedure well.


CPT Coding:
11771 Excision of pilonidal cyst or sinus; extensive

Rationale:
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.

In the CPT index, the term “pilonidal cyst” is listed with the subterm “excision.” It refers you to the code range 11770–11772. Code selection is dependent on whether the excision of the pilonidal cyst or sinus is simple, extensive, or complicated.

For a small or simple sinus, the physician uses a scalpel to completely excise the involved tissue. The wound is sutured in a single layer, and the procedure is reported with code 11770. An 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, and is reported with 11771. A complicated sinus has many subcutaneous extensions. The physician uses a scalpel to completely excise the involved tissue. Local soft tissue flaps may be required for closure of a large defect or the wound may be left open to heal by granulation. This procedure is reported with 11772.

In the procedure described above, the pilonidal cyst was extensive with subcutaneous extensions and appropriately reported with CPT code 11771.

ICD-9-CM Coding:
685.1 Pilonidal cyst without mention of abscess

Rationale:
The correct code is found in the ICD-9-CM index under the main term “Cyst” and the subterm “pilonidal (infected) (rectum)” which references code 685.1.

When category 685 is referenced in the tabular listing of ICD-9-CM, there are two codes: 685.0 Pilonidal cyst with abscess, and 685.1 Pilonidal cyst without mention of abscess. The physician’s documentation does not mention an abscess; therefore, it would be inappropriate to report code 685.0. CPT code 685.1 should be assigned for this procedure.

 
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