Epidermoid Cyst

Question:

My physician removed an epidermoid cyst and I am not certain how to code this. What CPT code is used for the removal of a 1.2 cm epidermoid cyst on the scalp that is removed through a small linear incision, is dissected and removed in total. I think I should use the I&D code 10060 but I am not sure. Can you help?

Answer:

Thank you for your question. Because the cyst was removed through a small linear incision, dissected free and removed in total (en bloc) from the scalp, this meets the definition of a benign lesion excision not an incision and drainage (I&D). The correct CPT code based on the 1.2cm size and anatomic location is 11422 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm).

*This response is based on the best information available as of 03/05/26.

Two Stage ACL Treatment

Question:

Our docs have been seeing more patients that have had a re-tear of ACL and are wanting to do bone grafting of tunnels in addition to medial and lateral meniscectomies and removal of hardware and evaluate the ACL to see if it repairable. We are wondering if the bone grafting is separately billable and what code we should use for this?

Answer:

Thank you for your inquiry and recognizing we are not able to provide definitive coding advice without an operative note. This is a good question.

There is no specific CPT code for the first of two stage revision of an ACL. Current guidance for the removal of plugs, debridement of tunnels and filling the tunnels with a bone substitute is coded to 29999. 

*This response is based on the best information available as of 03/05/26.

ICD-10 - Asymmetry Not Following Reconstruction

Question:

Looking for some ICD-10 advice from KZA. In instances in which a patient presents to our practice for breast asymmetry following lumpectomy, and no reconstruction has been performed, is N65.1 appropriate to report? If not, what is the proper ICD-10 code?

Answer:

Great question! Since no reconstruction has been performed, the ICD-10 code N65.1 is not appropriate, as that code specifically applies to disproportion of a reconstructed breast.

For cases of breast asymmetry following lumpectomy without reconstruction, the most accurate code is N64.89, which includes other specified breast disorders and is appropriate for asymmetry unrelated to reconstruction.

Using the correct diagnosis code supports accurate documentation, billing compliance, and quality reporting. Misapplying codes such as N65.1 may result in claim denials or inaccurate clinical data.

Thank you for reaching out to KZA with your inquiry.

*This response is based on the best information available as of 03/05/26.

E/M Leveling on a Recurrent Keloid

Question:

The patient has a recurrent keloid following surgical excision and is largely asymptomatic, with only occasional pruritus and burning. Does this fall under low or moderate medical decision making?

Answer:

Based on the condition alone, a recurrent keloid that is stable and only mildly symptomatic would generally meet Low MDM under the “Number and Complexity of Problems Addressed” element. However, the final MDM level cannot be determined without considering the other two MDM elements: data reviewed and the risk of treatment and management. If no data is reviewed and management is limited to observation, conservative measures, or a minor procedure with no risks the overall MDM would remain Low.

*This response is based on the best information available as of 03/05/26.

Nerve Transection CPT 64772

Question:

How do I code an AIN and/or PIN Neurectomy?

Answer:

You're question is excellent timing. CPT code 64772 Transection or avulsion of other spinal nerve, extradural is used for an AIN and/or PIN Neurectomy.  In January 2026, CMS increased the MUE (medically unlikely edit) for 64772 from 2 units to 6 units. 

*This response is based on the best information available as of 03/05/26.

Coding 61750 vs. 61751 for a Stereotactic Biopsy

Question:

We struggle with the code description for CPT 61750 vs 61751. Our providers load MRI and/or CT scans to a stereotactic navigation machine during surgery for Stereotactic biopsy, aspiration, or excision of a tumor. Which code would be correct when an MRI scan is used during surgery? The scan was done prior to going to the OR.

Answer:

Code 61751 is reported regardless of when the CT was performed, and it is typically performed before the patient goes to the OR.

*This response is based on the best information available as of 02/07/26.