2025 CPT code 10081
(Active) Effective Date: N/A Surgery - Incision and Drainage Procedures on the Skin, Subcutaneous and Accessory Structures Surgery Feed
Incision and drainage of pilonidal cyst; complicated.
Modifiers such as 22 (Increased Procedural Services), 51 (Multiple Procedures), 59 (Distinct Procedural Service), and others may be applicable depending on the specific circumstances of the procedure.
Medical necessity for this code is established by the presence of a symptomatic pilonidal cyst or abscess that requires surgical intervention for drainage and relief of symptoms.
The physician is responsible for the complete procedure, including pre-operative preparation, anesthesia, incision, drainage, irrigation, wound closure, and post-operative care.
In simple words: A complicated procedure to drain an infected cyst (pilonidal cyst) located at the base of the spine. This cyst contains hair and skin debris. The procedure involves opening the cyst, cleaning out the debris, and possibly placing a drain to help with healing.
The provider opens (incises) and drains the contents of a pilonidal cyst, a nest of hair and debris that forms at the base of the spine. This procedure requires extra time and technique to perform. After appropriate preparation and anesthesia, with the patient lying in the prone (face down) position, the provider incises the area over a pilonidal cyst just above the central buttock crease. They open the cyst and drain or scrape out the contents. If the cyst is extremely enlarged, it may require a layered closure and drain. The wound is thoroughly irrigated and the incision is sutured, in layers if necessary. The wound may be packed with gauze and allowed to heal by secondary intention, or a tube may be inserted into the wound before closing, which will be attached to a pump to help drain any fluid that continues to form.
Example 1: A patient presents with a large, infected pilonidal cyst that requires extensive drainage and layered closure with drain placement., A patient with a recurrent pilonidal cyst requires incision and drainage with complex wound management, including packing and secondary intention healing., A patient has a pilonidal abscess that requires incision, drainage, and insertion of a drainage tube connected to a pump for continuous fluid evacuation.
Documentation should include the size and location of the cyst, the complexity of the drainage procedure, the method of wound closure, and any drain placement.It should also detail the presence of infection and any associated complications.
- Revenue Code: P6A - MINOR PROCEDURES - SKIN
- Specialties:General Surgery, Colon and Rectal Surgery, sometimes Dermatology
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center