10060 Won’t Wash for Some I&Ds

January 14, 2010

Careful: A pilonidal cyst I&D is a separate animal.

Question: A patient presents to the ED reporting pain in her spine. During the exam portion of a level-three E/M, the physician discovers that the painful area is red, and slightly warm to the touch. The patient also has a low-grade fever that she says she noticed about two days ago. The physician makes a shallow incision with a scalpel at the base of the patient’s spine and drains the pus from the area. I reported 10060 and received a denial. Why?

Answer: You chose a standard incision and drainage (I&D) code when you should have opted for a pilonidal cyst I&D code. When you re-submit the claim, report the following:

• 10080 (Incision and drainage of pilonidal cyst; simple) for the I&D

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity …) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that it was separate from the I&D

• 685.0 (Pilonidal cyst; with abscess) appended to 10080 and 99283 to represent the patient’s injury.

Explanation: Typically, you’ll code simple I&Ds with 10060 (Incision and drainage of abscess [e.g., carbuncle, supprative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia; simple or single]) — a pilonidal cyst, however, is an exception.

When the physician performs I&Ds near the lower back or bottom of the coccyx, check to be sure he isn’t draining a pilonidal cyst, or you could miscode the encounter.

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