CCSD code H5940 – Pilonidal sinus excision with suture or skin graft

Key takeaways

CCSD code H5940 covers excision of a pilonidal sinus followed by closure with sutures or a skin graft, graded Intermediate.

A flap closure moves the claim to H5941, laying open moves it to H6020, and endoscopic ablation moves it to H6050.

Insurers code from the operative note, so the note must name the excision and the closure method in plain words.

Get the insurer’s authorisation number before surgery and quote it on the Healthcode claim with the ICD-10 diagnosis.

What CCSD code H5940 covers, and where it stops

CCSD code H5940 pays the consultant surgeon for excising a pilonidal sinus and then closing the wound. The schedule descriptor reads “Excision of pilonidal sinus and suture/skin graft”.

The code sits in Chapter 11 of the schedule (Abdomen, excluding urinary and reproductive organs), in the Rectum/anus section. It carries an Intermediate grade, which sets the benefit band insurers pay against.

Its number echoes OPCS-4 category H59, the NHS classification for pilonidal sinus excision. Private insurers bill against CCSD codes instead, so the claim carries H5940 rather than the OPCS code.

Inside the code

• Excision of the sinus tract, including the midline pits and any secondary openings.
• Closure of the defect with sutures, usually called primary closure.
• Closure with a skin graft where the defect is too wide to stitch.
• Routine steps in the same sitting, such as haemostasis, a drain and the first dressing.

Outside the code

• Flap reconstruction of the defect, which bills as H5941.
• Laying open of the tract without excision, which bills as H6020.
• Endoscopic treatment of the tract, which bills as H6050.
• The anaesthetist’s fee and the hospital charge, which those providers claim separately.

Drainage alone for an acute pilonidal abscess is a different operation again. Look up the drainage code in the insurer’s code search before you bill it.

Which pilonidal code fits? The operative note decides

Four CCSD codes cover pilonidal sinus surgery in the Rectum/anus section. Three are graded Intermediate and one is Minor, so the wrong pick changes the benefit.

Wording that points to each code

Billers code from the words on the page. These phrases in an operative note usually point one way.

• H5940: “excised en bloc”, “primary closure”, “closed in layers”, “split-skin graft”.
• H5941: “rhomboid flap”, “Limberg flap”, “advancement flap”, “Karydakis”, “cleft lift”.
• H6020: “laid open”, “unroofed”, “curetted and left to granulate”.
• H6050: “EPSiT”, “endoscopic”, “fistuloscope”, “ablated under direct vision”.

Off-midline repairs such as Karydakis and the Bascom cleft lift move tissue as a flap. If the note names one, check with the insurer before you choose between H5940 and H5941.

A worked example

A consultant excises a chronic sinus with two lateral openings. The note reads “sinus excised en bloc to the sacral fascia, primary midline closure over a drain”. That claim is H5940.

Now change one detail. The surgeon rotates a rhomboid flap to cover the defect instead. The excision is identical, but the closure makes it H5941.

Neither H5940 nor CCSD code H6020 describes an excision with the wound left open. When that happens, ask the insurer’s provider team how they want it coded before you submit.

Put together, the choice comes down to two questions, and the decision path below maps every answer to its code.

Pre-authorisation for H5940 starts before the theatre list

Pilonidal excision is elective surgery for most patients, and UK private medical insurers expect authorisation first. Operate without it and the whole fee is at risk.

The usual path runs from a GP referral to a consultant colorectal or general surgeon. The consultant confirms the indication and the planned technique. The patient, or your practice on their behalf, then requests authorisation and receives a reference number.

Each insurer publishes its own tools for checking the code and the benefit.

• Bupa: the Bupa code search lets consultants look up H5940 and the benefit attached to it.
• Aviva: the Aviva fee schedule lists approved amounts and any funding conditions.
• Vitality: the Vitality fee finder shows the benefit rate before you quote the patient.
• WPA: the WPA medical fees page sets out its schedule for consultants.
• AXA Health and others: confirm the authorisation route on the provider portal, then quote the reference on your bill.

Authorise the technique you plan, and name it. If theatre findings force a flap, ask the insurer to update the authorisation to H5941 as soon as you can.

Urgent cases, such as an abscess that needs same-day surgery, follow each insurer’s own rules for retrospective approval. Call promptly and note who you spoke to.

What the H5940 operative note must prove

The operative note is the evidence behind the code. A vague note invites a query, a downgrade or a rejection.

• The technique, by name: “excision” plus the closure method, such as “primary closure” or “split-skin graft”.
• Extent of disease: the number of pits, secondary openings and tracts excised.
• Closure detail: midline or off-midline, layers, any drain, and the graft donor site where used.
• Diagnosis: pilonidal cyst or sinus with abscess (ICD-10 L05.0) or without abscess (L05.9).
• Anaesthetic type: general, spinal or local, so the anaesthetist’s claim lines up with yours.
• Authorisation reference: the insurer’s number, recorded in the patient file before the operation.

Add a line on histology too. An excised specimen usually goes to the lab, and the report backs up the diagnosis if the insurer asks.

A structured operative note template prompts the surgeon for each field. The record then stops depending on memory at the end of a long list.

How an H5940 claim travels through Healthcode

Healthcode is the electronic billing hub most UK private insurers use for consultant claims. A clean H5940 claim usually moves in six steps.

1. Check the policy. Confirm the membership number and that cover is active on the operation date.
2. Record the authorisation. Store the insurer’s reference against the episode before admission.
3. Finalize the note. The surgeon signs off an operative note that names the excision and the closure method.
4. Build the bill. Enter H5940, the ICD-10 diagnosis, the operation date, your provider number and the authorisation reference.
5. Validate and send. Healthcode runs its checks for missing fields, then passes the bill to the insurer.
6. Track and reconcile. Follow the claim to payment, match the remittance to the invoice and chase any difference.

Your fee goes on its own bill. The anaesthetist and the hospital each send separate claims for their part of the same admission.

The insurer’s benefit can sit below your fee. Agree in writing with the patient who pays any shortfall before the operation, not after the remittance arrives.

Why H5940 claims come back unpaid

Most H5940 rejections trace back to the same handful of causes. Each one has a fix you can build into the workflow.

Two pilonidal codes on one bill for the same sinus also draw a query. Bill the single code that matches the technique performed.

Seven checks that save a pilonidal claim

Two minutes with this list catches most of the rejections above.

• The note names an excision and a suture or skin-graft closure, with no flap.
• The authorisation reference matches the code you are billing.
• The ICD-10 diagnosis is L05.0 or L05.9 and agrees with the clinical record.
• The operation date, membership number and provider number are correct.
• Only one pilonidal code appears on the bill for this sinus.
• The patient has agreed in writing to any shortfall.
• The anaesthetist and the hospital have the details they need for their own bills.

For the wider picture of how insurers apply the schedule, see our guide to Bupa CCSD codes.

Send H5940 claims straight from the patient record

Pilonidal claims usually stall on paperwork rather than surgery. The authorisation number sits in an email, the note sits in a dictation file, and the bill gets built from memory.

Pabau, the practice management platform we build, connects directly to Healthcode. The claim is raised from the patient record, so the CCSD code and diagnosis come from what is already documented.

Before the claim can go, Pabau checks that required fields such as the membership number and authorisation code are filled in. Each claim is then tracked through to payment and reconciled against the remittance.

The coding decision stays with the surgeon, because Pabau does not choose between H5940 and H5941. What changes is that the code, diagnosis and authorisation travel together in one claims management software record.

Send cleaner pilonidal claims through Healthcode

Pabau raises the claim from the patient record and checks the required fields. It then sends the claim through Healthcode and tracks it to payment.

Book a demo

Conclusion

H5940 belongs to one operation: excise the pilonidal sinus, then close it with sutures or a skin graft. Add a flap and the claim becomes H5941. Lay the tract open instead and it drops to H6020, a Minor procedure.

In practice, the surgeon picks the code while dictating the note. Name the closure method, match it to the authorisation and quote the diagnosis, and the insurer has little left to query.

To see a checked H5940 claim travel from the patient record through Healthcode to payment, book a demo.

Continue your research

Billing the laying-open technique instead? CCSD code H6020: laying open of pilonidal sinus covers the Minor-graded alternative to excision.

Coding fistula surgery in the same section? CCSD code H5520: laying open of high anal fistula explains documentation and claims for that procedure.

Claiming for rectal prolapse repair? CCSD code H4200: perineal repair of prolapse of rectum walks through pre-authorisation and billing.

Billing transanal surgery as well? CCSD code H4000: transanal resection for local rectal growth shows how to code and claim it for UK insurers.

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