A patient presents to his physician today complaining of pain in the left gluteal area. The physician gathers an expanded problem-focused history and performs an expanded problem-focused examination and decision making of straightforward complexity, determining that the cause of the pain is an infected sebaceous cyst in this area. An incision and drainage of the cyst is performed. Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct ICD-10-CM code for an infected sebaceous cyst is L72.3. The CPT code for incision and drainage of a simple or single abscess is 10060. The CPT code for an office visit for evaluation and management of an established patient, which requires at least an expanded problem-focused history and examination and straightforward decision making, is 99213. Modifier -25 is used to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the procedure.

A Patient Presents to His Physician Today Complaining of Pain