2025 ICD-10-CM code L05.02
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Infections - Infections of the skin and subcutaneous tissue Diseases of the skin and subcutaneous tissue (L00-L99) Feed
Pilonidal sinus with abscess. This code represents an infected pilonidal sinus, characterized by an abscess.
Medical necessity for treatment is established by the presence of a symptomatic pilonidal sinus with abscess, causing significant pain, infection, and impairment of daily activities.The severity of the infection necessitates incision and drainage or surgical excision based on the clinical judgment of the treating physician.
Diagnosis and treatment of the pilonidal sinus and abscess by a physician or other qualified healthcare professional. This may involve incision and drainage of the abscess, debridement, antibiotic administration, and possible surgical intervention for recurrent or complex cases.
- Diseases of the skin and subcutaneous tissue (L00-L99)
- L00-L08 (Infections of the skin and subcutaneous tissue)
In simple words: This code describes an infected pilonidal sinus, which is a small hole or tunnel near the tailbone that gets infected and filled with pus. This infection causes pain, swelling, and redness in the area.
L05.02, in the ICD-10-CM classification, signifies a pilonidal sinus with an accompanying abscess.A pilonidal sinus is a small cavity or tunnel that forms in the skin, usually in the cleft between the buttocks.When infected, it can lead to the development of an abscess, a localized collection of pus.This condition presents with pain, swelling, redness, and potentially drainage of pus or blood from the affected area. The diagnosis requires clinical examination, potentially supplemented by imaging studies to assess the extent of the infection.
Example 1: A 25-year-old male presents with pain, swelling, and redness in the gluteal cleft. Examination reveals a fluctuant abscess within a pilonidal sinus. Incision and drainage are performed, and antibiotics are prescribed., A 30-year-old female reports recurrent episodes of pain and drainage from a pilonidal sinus.She has had previous episodes of abscess formation.The physician recommends surgical excision of the sinus tract to prevent future recurrences., A 40-year-old male presents with a large, fluctuant abscess in the pilonidal region, accompanied by fever and significant pain. He undergoes surgical drainage, receives intravenous antibiotics, and is admitted for observation.
Detailed history and physical examination documenting the location, size, and characteristics of the abscess and sinus tract.Documentation of incision and drainage procedure, including the amount and character of drainage.Results of any cultures obtained.If surgical excision was performed, operative notes describing the procedure and findings.
** The presence of a fistula associated with the pilonidal sinus is typically not explicitly coded separately in ICD-10-CM but is implicitly included in the diagnosis of pilonidal sinus with abscess.Consideration should be given to additional codes to identify the causative infectious agent if determined.
- Payment Status: Active
- Specialties:Surgery, General Practice, Dermatology
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center, Emergency Room - Hospital