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Pilonidal Cyst/Abscess

Incision and Drainage (I&D)

Madalina Pitu

UT Health Science Center at Houston

Diagnostic Tests and Procedure

N6551 Fall 2021

Pilonidal cysts- A pain in the butt

What is ?

  • Pilonidal cysts are caused by ingrown hair and skin debris. These abnormal pockets can become infected and form an abscess causing extreme discomfort or pain.
  • Located over the tailbone or close to the anus in the gluteal folds
  • Treated with incision and drainage

  • Occurs in Males > females.
  • Younger > older.
  • Obesity
  • Prolonged sitting
  • The problem may reoccur.

Risk factors

Cyst vs. Abscess

Usually caused by: Staphylococcus aureus

Streptococcus species

Diagnosis

Cyst that is painful

Swelling

Redness

Drainage

Foul smell

Fever

When?

When would you perform a pilonidal I&D?

Indications for I&D

1.

Collection of pus causing pain that has not been relieved by use of antibiotics or non-invasive methods

Indications

2.

Small abscess that enlarged, or large abscess

Need to eliminate discomfort and promote healing

3.

Contraindications

1.

Debilitating disease or

Immunocompromised

Contraindications

2.

Excessively large or deep abscesses

3.

Multiple reoccurring pilonidal abscesses may indicate need for surgical removal

Beware

Things to be mindful of

Complications

  • Pain – during and after procedure
  • Bleeding
  • Reoccurrence of abscess
  • Septic thrombophlebitis
  • Formation of fistula
  • Necrotizing fasciitis
  • Damage to nerves and vessels
  • Scarring

Informed consents are required!

Must have

Procedure

Procedure

Equipment

Equipment

  • Antiseptic skin cleaner ex: hibiclens
  • Topical anesthetic
  • Lidocaine – 1% or 2%, with or without epi
  • 3-10mL syringe
  • 27-30 gauge, ½ inch needle
  • Sterile 4x4 gauze
  • No.11 scalpel
  • Steril drape
  • Sterile gloves
  • Curved hemostats – sterile
  • Iodoform gauze
  • Scissors – sterile
  • Culture swap

  • Position patient so abscess is easily accessible- prone or left lateral
  • Set up your sterile field
  • Clean the abscess and surrounding skin with antiseptic cleaner – 3 inch diameter
  • Drape the abscess with sterile drape

Prep

Incision and Drainage how-to

I&D

  • Put on sterile gloves
  • Anesthetize the perimeter around the abscess with lidocaine. Do not inject lidocaine into the abscess.
  • Use your scalpel to make a deep and long incision to allow drainage of the pus and prevent premature closure. Manually express pus from abscess
  • Obtain culture by swabbing deep in the wound
  • Probe sinus tract with cotton tipped applicator- if deep refer to surgeon
  • If sinus tract is superficial, less than 5mm, perform elliptical excision for pilonidal sinus
  • Explore the wound, remove hair and breakdown any septa or sacs with curved hemostat
  • Pack with iodoform gauze, leave a little protruding from wound
  • Dress with sterile gauze

Medications and Follow up

After Care

  • Antibiotics not necessary
  • Pain management
  • Tylenol #3 Q4-6 hours for the first 24 hours, then ibuprofen
  • Return to office in 2 days to remove packing if indicated
  • Wound care
  • Offloading
  • Keeping site clean
  • Sitz baths
  • Observe for signs of infection
  • Pus continues after 5 days
  • Redness, swelling, pain increases, fevers

Getting paid

Document

Documentation and Billing

  • Patient name and medical record number, Name of provider performing procedure, date/time, Hx, HPI, ROS, diagnosis, plan.
  • Rational for ordering procedure
  • Risk factors
  • Procedural note:
  • Anesthetic used
  • Identify the I&D anatomical spot
  • Identify if abscess or cyst
  • Identify if simple or complicated

CPT vs ICD codes

  • CPT is the treatment being given
  • ICD is the diagnosis or problem needing treatment

Using the correct code

  • Identify the I&D anatomical spot
  • Pilonidal!!
  • Identify if abscess or cyst
  • Abscess has pus
  • Cyst is removed with the epithelial lining
  • Identify if simple or complicated
  • Simple if drained and left open
  • Complicated with tube, drain, or packing was needed

Using the correct code

Why is this important??

  • Auditing vs revenue lose

10061 vs 10081= $ 31.69

  • if you do 20 a month, you’re losing $7,605.60 a year

10060 vs. 10081= $154.40

  • if you do 20 a month, you’re losing $37,056 a year

References

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