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 10060 is for incision and drainage of an abscess (simple or single), which matches the procedure described. The CPT code 99213-25 indicates an office visit for an established patient that required an expanded problem-focused history and examination with straightforward decision making, and the modifier -25 indicates that this was a significant, separately identifiable service from the procedure performed on the same day.

A Patient Presents to His Physician Today Complaining of Pain