Coding Ahead
CasePilot
Medical Coding Assistant
Case2Code
Search and Code Lookup Tool
CareerCenter
Medical Coding Job Board
Log in Register free account

Need help choosing the right code?

Ask CasePilot about procedures, modifiers, bundling, and coding guidance.

Try CasePilot

Official Description

Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

Acne surgery encompasses a variety of procedures aimed at treating acne lesions, which can manifest in different forms. The official description of CPT® Code 10040 includes techniques such as marsupialization, as well as the opening and removal of multiple milia, comedones, cysts, and pustules. Acne is a common skin condition characterized by the presence of various types of lesions, each requiring specific treatment approaches. Milia, often referred to as whiteheads, and comedones, known as blackheads, are examples of non-red, non-inflamed lesions that can be effectively treated through mechanical extraction methods. In contrast, cysts and pustules are inflamed lesions that typically present as red and require more invasive interventions. The removal of comedones is generally performed using an extractor tool, while milia are typically opened and excised with a needle or fine blade. For cysts and pustules, the procedure involves incising the lesion to allow for drainage of the contents. Although marsupialization is a technique that can be employed, it is less commonly used due to the potential for scarring, as it involves resecting the wall of the cystic lesion. Overall, acne surgery aims to alleviate the physical manifestations of acne and improve the patient's skin condition.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 10040 is indicated for the treatment of various types of acne lesions. The specific indications include:

  • Milia - These are small, white cysts that typically appear on the face, particularly around the eyes and cheeks, and are often resistant to topical treatments.
  • Comedones - This term refers to both open (blackheads) and closed (whiteheads) lesions that result from clogged hair follicles, which can lead to inflammation if not treated.
  • Cysts - These are larger, inflamed lesions that can be painful and may require surgical intervention to prevent further complications.
  • Pustules - These are inflamed lesions filled with pus, indicating an active infection that may necessitate drainage to alleviate discomfort and promote healing.

2. Procedure

The procedure for acne surgery as described in CPT® Code 10040 involves several distinct steps, each tailored to the type of lesion being treated. The following procedural steps are typically performed:

  • Step 1: Identification of Lesions - The first step involves a thorough examination of the patient's skin to identify the specific types of acne lesions present, including milia, comedones, cysts, and pustules. This assessment is crucial for determining the appropriate treatment approach for each lesion type.
  • Step 2: Preparation of the Treatment Area - Once the lesions are identified, the treatment area is cleansed to reduce the risk of infection. This may involve the use of antiseptic solutions to prepare the skin for the procedure.
  • Step 3: Mechanical Extraction of Comedones - For comedones, a specialized extractor tool is used to apply pressure around the clogged follicle, allowing for the mechanical removal of the contents. This step is performed with care to minimize trauma to the surrounding skin.
  • Step 4: Opening and Removal of Milia - Milia are typically treated by using a sterile needle or fine blade to make a small incision in the skin over the cyst. The contents are then gently expressed or removed to eliminate the lesion.
  • Step 5: Incision and Drainage of Cysts and Pustules - For cysts and pustules, the procedure involves making an incision to allow for drainage of the pus or fluid. This step alleviates pressure and discomfort associated with these inflamed lesions.
  • Step 6: Marsupialization (if applicable) - In cases where marsupialization is deemed necessary, the wall of the cystic lesion is resected to create a permanent opening. This technique is less commonly used due to the potential for scarring.
  • Step 7: Post-Procedure Care - After the lesions have been treated, the area may be cleaned again, and appropriate dressings may be applied to protect the skin as it heals.

3. Post-Procedure

Post-procedure care following acne surgery is essential for optimal healing and to minimize the risk of complications. Patients are typically advised to keep the treated area clean and dry, avoiding any harsh skincare products or exfoliants for a specified period. It is also important to monitor the area for signs of infection, such as increased redness, swelling, or discharge. Patients may be instructed to apply topical antibiotics or ointments as prescribed to promote healing. Follow-up appointments may be scheduled to assess the healing process and determine if any additional treatments are necessary. Overall, proper post-procedure care is crucial for achieving the best possible outcomes and preventing recurrence of acne lesions.

Short Descr ACNE SURGERY
Medium Descr ACNE SURGERY
Long Descr Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)
Status Code Active Code
Global Days 010 - Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator STV-Packaged Codes
ASC Payment Indicator Packaged service/item; no separate payment made.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6A - Minor procedures - skin
MUE 1
CCS Clinical Classification 168 - Incision and drainage, skin and subcutaneous tissue
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
GZ Item or service expected to be denied as not reasonable and necessary
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
AG Primary physician
AM Physician, team member service
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GX Notice of liability issued, voluntary under payer policy
KX Requirements specified in the medical policy have been met
LT Left side (used to identify procedures performed on the left side of the body)
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
SA Nurse practitioner rendering service in collaboration with a physician
TA Left foot, great toe
U7 Medicaid level of care 7, as defined by each state
X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"