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 correct CPT code for incision and drainage of a simple or single abscess is 10060. The additional CPT code 99213-25 represents an office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision making of low complexity. Modifier -25 is used to indicate that the evaluation and management service on the day of the procedure was significant and separately identifiable from the procedure itself.

A Patient Presents to His Physician Today Complaining of Pain