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2025 ICD-10-CM code L05.9

Pilonidal cyst and sinus without abscess.

Use L05.91 for a pilonidal cyst without abscess and L05.92 for a pilonidal sinus without abscess.Do not use L05.9 if an abscess is present; instead, use L05.0.

Medical necessity for treatment of a pilonidal cyst without abscess is generally established by the presence of symptoms such as pain, discomfort, or recurrent drainage. Asymptomatic cysts may not require intervention.

Physicians, particularly dermatologists and general surgeons, are responsible for diagnosing and managing pilonidal cysts and sinuses.This includes physical examination, determining the presence or absence of infection, and recommending appropriate treatment, which may range from conservative management to surgical intervention.

IMPORTANT:L05.91 (Pilonidal cyst without abscess), L05.92 (Pilonidal sinus without abscess). Use additional code (B95-B97) to identify infectious agent if present.Do not use this code with L05.0 (Pilonidal cyst with abscess).

In simple words: This code indicates a pilonidal cyst, a small lump or sac containing hair and skin debris, located near the tailbone, which is not currently infected.

This code represents a pilonidal cyst and sinus without the presence of an abscess. A pilonidal cyst is a closed sac that typically contains hair and skin debris, located in the cleft at the top of the buttocks. A pilonidal sinus is a small tunnel or channel that connects the cyst to the skin surface.This condition can occur when hair punctures the skin and becomes embedded.While often asymptomatic, pilonidal cysts and sinuses can become infected and painful.

Example 1: A 25-year-old male presents with a small, asymptomatic lump in the natal cleft.Examination reveals a pilonidal cyst without signs of infection. The appropriate code is L05.9., A 30-year-old female has a history of recurrent pilonidal cysts. She currently has a pilonidal sinus with occasional drainage but no signs of active infection. The correct code is L05.92., A patient with a previously diagnosed pilonidal cyst returns for a follow-up appointment. The cyst is smaller and no longer symptomatic.There is no evidence of infection. The appropriate code is L05.91

Documentation should include the location and characteristics of the cyst or sinus, the presence or absence of an abscess or infection, and any associated symptoms.If a sinus is present, its characteristics, such as drainage, should also be documented.Previous history of pilonidal cysts should be noted.

** It's crucial to distinguish between a pilonidal cyst and a pilonidal sinus, as well as to accurately document the presence or absence of an abscess.For accurate coding, use the iFrameAI product for the latest information.

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iFrame™ AI's knowledge is aligned with and limited to the materials uploaded by users and should not be interpreted as medical, legal, or any other form of advice by iFrame™.