CPT 10080Surgery

I&d pilonidal cyst simple

CPT code 10080 covers the simple drainage of a pilonidal cyst, a painful pocket of infection that typically forms near the tailbone. The procedure involves making a small incision to drain fluid and relieve pressure.

Showing rates for

National Average

Base Medicare rate

$238.39

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.22

PE RVU (NF)

5.95

MP RVU

0.2

Total RVU

7.37

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always verify place of service code—POS 11 (office) yields $238.39 vs POS 22 (outpatient hospital) yields $103.19, a $135.20 difference per procedure
Impact: $135.20 revenue loss if billed with incorrect POS; ensure office-based procedures use POS 11 to capture full non-facility rate
Document 'simple' explicitly in operative note to differentiate from 10081 (complicated); absence of sinus tract excision, marsupialization, or extensive debridement supports 10080
Impact: Prevents downcoding from 10081 ($422.04 non-facility) if documentation unclear; improper upcoding to 10081 triggers high audit risk
Bill same-day E/M with modifier 25 only when documentation shows separate medical decision-making beyond procedure consent and site preparation (e.g., evaluation of systemic infection, comorbidity management)
Impact: Potential $75-150 additional revenue but 40-60% audit rate for modifier 25; requires distinct diagnosis or comprehensive assessment documentation
Use ICD-10 code L05.01 (pilonidal cyst with abscess) rather than L05.91 (pilonidal cyst without abscess) to support medical necessity for I&D
Impact: L05.91 may trigger denial for lack of drainage indication; L05.01 has 95%+ approval rate for 10080 claims
For commercial payers, verify if prior authorization required for office procedures; many bundled payment models exclude minor surgeries from ASC authorization requirements
Impact: Prevents automatic denials for lack of authorization; commercial rates typically 150-250% of Medicare ($357-595 range)
Submit claims within 30 days for optimal payment; pilonidal I&D has lower-than-average clean claim rate (72%) due to missing diagnosis specificity

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 10080 in 2025?

The 2025 Medicare national average reimbursement is $238.39 for non-facility (office) settings and $103.19 for facility settings. The rate difference reflects higher practice expense RVUs (5.95 vs 1.77) when the physician provides equipment and staff in an office-based setting.

What is the difference between CPT 10080 and 10081?

CPT 10080 is for simple pilonidal cyst drainage involving straightforward incision and evacuation, while 10081 covers complicated drainage requiring sinus tract excision, marsupialization, or extensive debridement. The complicated version (10081) reimburses at $422.04 non-facility versus $238.39 for simple drainage, but requires documentation of complex features.

Can I bill an E/M code with CPT 10080 on the same day?

Yes, you can bill a separate E/M service with modifier 25 if documentation supports a significant, separately identifiable evaluation beyond the minor assessment inherent to the procedure. The E/M must address different aspects of care, such as systemic infection evaluation, comorbidity management, or unrelated conditions, and must be clearly documented as distinct from procedure consent and preparation.

How many RVUs is CPT code 10080 worth?

CPT 10080 has a total of 7.37 RVUs: 1.22 work RVUs, 5.95 non-facility practice expense RVUs (1.77 facility), and 0.20 malpractice RVUs. These RVUs multiplied by the 2025 conversion factor of 32.3465 determine the Medicare payment rates.

What diagnosis codes support medical necessity for CPT 10080?

The primary supporting diagnosis codes are L05.01 (pilonidal cyst with abscess) and L05.02 (pilonidal sinus with abscess). These codes clearly indicate infection requiring drainage. Avoid L05.91 (pilonidal cyst without abscess) as it may not support medical necessity for incision and drainage procedures.

Does CPT 10080 have a global period?

Yes, CPT 10080 has a 10-day global period, meaning routine post-operative care within 10 days is included in the reimbursement. Services during this period for complications or unrelated issues may require modifiers 24 (unrelated E/M), 78 (return to OR), or 79 (unrelated procedure) to obtain separate payment.

What is the typical commercial insurance reimbursement for CPT 10080?

Commercial insurance typically reimburses 150-250% of Medicare rates, translating to approximately $357-$595 for office-based pilonidal cyst drainage. Actual rates vary significantly by payer contract, geographic location, and network status. Always verify benefits and contracted rates before performing elective procedures.