Tanesha Posted Tue 13th of November, 2018 18:20:35 PM
11770 or 11771? This appears to be 11770. Excerpt: Sacral area was prepped. The patient had a tube draining pin hole sites in the upper buttock crease both of which were fluctuant and drained some pus. Gentle blunt dissection revealed 2 cm pocket inferiorly and a 3 cm pocket or abscess cavity superiorly. Significant amount of hair was removed from both abscess cavities. The sites were irrigated and debrided of fibrinous tissue. The common wall between abscess cavities was punctured and 2 blue vessel loops were passed from one site to the other after both of which were cored out with Trephine punch biopsies. The vessel loops were looped back to themselves to allow for consistent drainage. The cephalad abscess was packed with 30 cm of half-inch iodoform gauze whereas the inferior abscess cavity was packed with 20 cm of iodoform Nu gauze.
SuperCoder Answered Wed 14th of November, 2018 02:29:45 AM
Thanks for your question.
This should be coded as simple with CPT code 11770 (Excision of pilonidal cyst or sinus; simple).
CPT code 11771 (extensive) is reported when the pilonidal cyst(s) is extensive in nature (spread to subcutaneous tissue layer). Look for the terms like "extended," "extensive," "deeply rooted," etc. in the documentation.
Please feel free to write if you have any question.
Tanesha Posted Wed 14th of November, 2018 08:01:50 AM
SuperCoder Answered Wed 14th of November, 2018 23:54:59 PM
Thank you, happy to help.