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2025 ICD-10-CM code L05.92

Pilonidal sinus without abscess. This condition involves a cyst or sinus located in the cleft at the top of the buttocks.

Use additional code (B95-B97) to identify infectious agent if present. Do not use this code if there is an active abscess.

Medical necessity for treatment of a pilonidal sinus without abscess is based on the patient's symptoms and the potential for future infection or complications.Asymptomatic sinuses may not require intervention.

Diagnosis and management of pilonidal sinus typically falls under general surgery, colorectal surgery, or dermatology.

In simple words: A pilonidal sinus is a small hole or tunnel in the skin at the top of the buttocks that can sometimes get infected.

Pilonidal sinus without abscess.A pilonidal sinus is a small hole or tunnel in the skin at the top of the buttocks, where the tailbone is. It can sometimes become infected. Other names for this condition include coccygeal fistula, coccygeal sinus, and pilonidal cyst.

Example 1: A 25-year-old male presents with pain and tenderness in the sacrococcygeal region. Examination reveals a small opening with minimal drainage but no signs of abscess. The diagnosis is a pilonidal sinus without abscess (L05.92)., A 30-year-old female incidentally discovers a small dimple in the natal cleft during a self-exam. There is no pain, swelling, or discharge.This is documented as a pilonidal sinus without abscess (L05.92)., A patient with a history of recurrent pilonidal abscesses is seen for follow-up after surgical treatment. The wound is healing well, and there is no current infection. The current status is coded as a pilonidal sinus without abscess (L05.92) since the acute infection has resolved.

Documentation should include the location and characteristics of the sinus, presence or absence of infection (redness, swelling, purulent drainage, fever), and any associated symptoms (pain, tenderness).

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