Pilonidal Cyst Excision
11770
-
11771— Excision of pilonidal cyst or sinus, extensive -
11772— Excision of pilonidal cyst or sinus, complicated -
14000— Adjacent tissue transfer/rearrangement (flap closure) -
10080— Incision and drainage, pilonidal cyst, simple -
10081— Incision and drainage, pilonidal cyst, complicated
Pilonidal cyst / sinus disease — [acute abscess / chronic / recurrent]
Pilonidal [cyst / sinus] — [simple / extensive / with multiple pits / with lateral extensions]
Excision of pilonidal cyst/sinus with [open wound packing / primary midline closure / off-midline closure / Karydakis flap]
[Attending name], MD/DO
[Resident/PA name]
[Spinal / general / MAC]; local — [X] mL 0.25% bupivacaine with epinephrine
The patient is a [age]-year-old [male/female] with a [duration] history of [recurrent / chronic / acutely infected] pilonidal disease presenting for definitive surgical excision. [Prior incision and drainage on (date) / recurrent episodes noted.] The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.
In the prone jackknife position, [number] midline pits were identified in the natal cleft overlying the sacrococcygeal region. [Lateral extensions / sinus tracts were / were not present]. The cyst measured approximately [X × X] cm. [Purulent / sebaceous / hair-containing] material was present. The cyst did not extend to the sacral periosteum.
The patient was placed in the prone jackknife position with the buttocks taped laterally to expose the natal cleft. [Anesthesia type] was induced. A surgical timeout was performed. The sacrococcygeal region was prepped with betadine and draped in sterile fashion. Local anesthesia was supplemented with [X] mL of 0.25% bupivacaine with epinephrine at the operative site.
The pilonidal pits were identified and probed to delineate the extent of the sinus tracts. A probe [or methylene blue dye injection] was used to define the extent of the disease. An elliptical incision was made encompassing all pits and sinus tracts, placed off the midline to the [right / left] with adequate margins. The dissection was carried down to the presacral fascia, excising the entire cyst and all associated sinus tracts en bloc.
The specimen was delivered and inspected — the entire sinus tract with all pits appeared to be included. The wound was inspected for residual hair, debris, or granulation tissue, which were removed. The wound was irrigated with normal saline.
[Open packing:] The wound was left open and packed with [iodoform / plain] gauze. The patient will require regular dressing changes until healing by secondary intention.
[Primary or off-midline closure:] The wound edges were mobilized. The wound was closed in layers with [2-0 Vicryl] deep dermal sutures and [3-0 Monocryl] subcuticular sutures, placing the skin closure [off the midline / in the midline]. A closed suction drain was [placed / not placed].
[Karydakis flap:] An asymmetric elliptical excision was made off the midline. The contralateral skin flap was advanced and secured off the midline using [2-0 Vicryl / 3-0 Monocryl] sutures, flattening the natal cleft and moving the suture line away from the midline.
None
Pilonidal cyst and sinus tract sent to pathology
Minimal (less than 20 mL)
None / [Closed suction drain — removed when output < 30 mL/day]
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition. Wound care instructions were provided. [Follow-up for wound check / packing change in 2–3 days was arranged.]
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Pilonidal disease — ***
POSTOPERATIVE DIAGNOSIS: Pilonidal *** — *** pits, ***
PROCEDURE PERFORMED: Excision of pilonidal cyst/sinus with ***
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***; local — *** mL 0.25% bupivacaine with epinephrine
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** pilonidal disease presenting for definitive excision. Risks, benefits, and alternatives discussed, consent obtained.
FINDINGS: *** midline pits in natal cleft. Lateral extensions: ***. Cyst *** × *** cm. No extension to sacral periosteum.
DESCRIPTION OF PROCEDURE:
Patient prone jackknife, buttocks taped. *** anesthesia. Timeout. Prepped and draped.
Pits identified and probed. *** used to delineate sinus tracts. Off-midline elliptical incision encompassing all pits/tracts. Dissection to presacral fascia — cyst and tracts excised en bloc. Wound inspected — no residual hair or debris. Irrigated.
Wound closure: ***. [Drain: ***.]
EBL: Minimal
SPECIMENS: Pilonidal cyst and sinus to pathology
COMPLICATIONS: None
DISPOSITION: Patient taken to PACU in stable condition. Wound care instructions provided.
Signed: .ME, .MYDEGREE
.TODAYVariants
Open Wound — Secondary Intention Healing
Given [active infection / extensive disease / prior failed primary closure / patient preference], the wound was left open for healing by secondary intention. The wound was packed with iodoform gauze. The patient was instructed on daily wet-to-dry packing changes [or instructed to use a handheld shower head]. Average healing time is [6–12 weeks]. Follow-up was arranged for wound checks. The patient was counseled on hair removal (laser epilation or shaving) of the natal cleft to reduce recurrence risk.
Karydakis Flap Closure
An off-midline (Karydakis) closure was performed. An asymmetric elliptical excision removed the disease while biasing the closure to one side. The contralateral dermis was mobilized and advanced to achieve a tension-free closure placed away from the midline, flattening the natal cleft. Deep closure with [2-0 Vicryl] interrupted sutures, skin closed with [3-0 Monocryl] subcuticular suture. A closed suction drain was placed. This technique has lower recurrence rates than midline closure.
Recurrent Pilonidal Disease
This was the patient's [second / third] surgical procedure for pilonidal disease. Prior scar tissue was excised widely. Recurrent sinus tracts were identified and excised completely. Given the extent of tissue loss and prior failed midline closure, an off-midline [Karydakis / rhomboid / Limberg] flap was constructed to provide tension-free wound closure with well-vascularized tissue and to recontour the natal cleft.
Charting Tips
- Document the number of pits identified and whether all were excised — recurrent pilonidal disease is almost always due to retained pits or incompletely excised sinus tracts. Explicitly stating that all pits were excised is the most important medicolegal documentation.
- Document the closure type and rationale — off-midline closure has significantly lower recurrence rates than midline closure. If midline closure was chosen, document the reason. If open packing was chosen, document the rationale (infection, extensive disease).
- For recurrent disease, document that the prior operative site and all scar tissue were included in the excision. In revision cases, the boundaries of prior surgery should be defined and excision extended beyond the prior operative field.
Billing Tips
- Bill 11770 for simple pilonidal cyst excision (2.59 wRVU, 10-day global). Use for incision and removal of a small, uncomplicated pilonidal cyst without extensive tissue removal.
- Bill 11771 for extensive pilonidal cyst excision (5.94 wRVU, 90-day global) when wide excision of a larger cyst or sinus tract is required. Bill 11772 for complicated excision (7.17 wRVU, 90-day global) when the cyst is complex, recurrent, or involves multiple tracts.
- Code selection depends on the extent of excision, not whether primary closure or open packing is used. Document the dimensions of tissue excised and the number of sinus tracts removed.
- 10-day global (11770) vs. 90-day global (11771/11772): wound packing changes for an open pilonidal wound within the global period are bundled for 11771/11772 — do not bill separate E/Ms for wound checks unless a new problem is addressed.
- Flap closure (Limberg, Karydakis) does not change the pilonidal excision CPT — bill the appropriate excision code plus a flap repair code (14000-14302) as a secondary procedure with modifier -51.