cubbiecatz
Networker
I'm not sure what CPT to use for the I&D of the pelvic abscess. Am I going to have to use an unlisted code?
Procedures Date: 12/10/2025 - 12/15/2025
Date of Service: 12/15/2025
Pre-op Diagnosis:
. Status post hysterectomy
7 cm pelvic abscess
Post-operative Diagnosis: same, status post abscess drainage
Procedures:
A4 PELVIC EXAMINATION UNDER ANESTHESIA
I & D PELVIS
Surgeon(s):
Anesthesia: General
Staff:
* No Diagnosis Codes entered *
Anesthesia: General LMA anesthesia
Findings:
Vaginal cuff intact, slight area of erythema on the right apex. Small amount of serosanguineous fluid drained.
Estimated Blood Loss: 10 ml
Urine output: Clear to Foley
Specimens: Aerobic anaerobic cultures obtained
Complications: None; patient tolerated the procedure well.
Indication and Consent:
Patient has a history of pelvic abscess after hysterectomy.
Abscess was not accessible by interventional radiology. Patient consented for abscess drainage. She was counseled on risks of bleeding, damage to nearby organs including the bowel, bladder, ureters. We discussed the benefit of drainage of the abscess to expedite recovery. All of her questions addressed and answered.
Procedure Details:
The patient was taken to Operating Room, and the procedure verified. A Time Out was held and the above information confirmed.
General anesthesia was administered without difficulty. She was placed in dorsal lithotomy position in Allen type stirrups. Patient was prepped and draped in the normal sterile fashion. Next, a weighted speculum was placed in the vagina. Vaginal cuff noted to be intact, slight area of erythema at the left apex.
The cuff was grasped with Allis clamps. The area of erythema was probed with a size 2 Hegar dilator. This was eventually expanded to a size 4 Hegar dilator. Hemostat used to expand the opening on the vaginal cuff. As the cuff continued to expand and open, slight serosanguineous drainage noted. At this point swabs were obtained for culture and Gram stain. Suction of this area showed slight loculated material.
Foley catheter placed at this time. Next transabdominal ultrasound showed small pocket of fluid in the suprapubic region off to the patient's left. This was palpated with fingers and seen on ultrasound. Hegar dilator probed in this area and more serosanguineous fluid noted. Second swab obtained from this area.
Next a JP drain was placed and sewn to the anterior cuff with silk suture. The vaginal cuff was reapproximated with 2-0 PDS sutures and figure-of-eight stitches. Vaginal cuff noted to be hemostatic and JP drain in position. The drain was hooked up to bulb suction with slight serosanguineous fluid noted.
After the procedure, all instruments were removed from the vagina. Vaginal cuff noted to be hemostatic and urine noted to be clear. The patient tolerated the procedure well. All counts were correct. The patient was taken from the operating room in stable condition after she was cleaned.
The patient will return to her room postoperatively. Plan to monitor drain output and repeat CT scan as needed.
Disposition: PACU - hemodynamically stable.
Condition: stable
Thank you
Procedures Date: 12/10/2025 - 12/15/2025
Date of Service: 12/15/2025
Pre-op Diagnosis:
. Status post hysterectomy
7 cm pelvic abscess
Post-operative Diagnosis: same, status post abscess drainage
Procedures:
A4 PELVIC EXAMINATION UNDER ANESTHESIA
I & D PELVIS
Surgeon(s):
Anesthesia: General
Staff:
* No Diagnosis Codes entered *
Anesthesia: General LMA anesthesia
Findings:
Vaginal cuff intact, slight area of erythema on the right apex. Small amount of serosanguineous fluid drained.
Estimated Blood Loss: 10 ml
Urine output: Clear to Foley
Specimens: Aerobic anaerobic cultures obtained
Complications: None; patient tolerated the procedure well.
Indication and Consent:
Patient has a history of pelvic abscess after hysterectomy.
Abscess was not accessible by interventional radiology. Patient consented for abscess drainage. She was counseled on risks of bleeding, damage to nearby organs including the bowel, bladder, ureters. We discussed the benefit of drainage of the abscess to expedite recovery. All of her questions addressed and answered.
Procedure Details:
The patient was taken to Operating Room, and the procedure verified. A Time Out was held and the above information confirmed.
General anesthesia was administered without difficulty. She was placed in dorsal lithotomy position in Allen type stirrups. Patient was prepped and draped in the normal sterile fashion. Next, a weighted speculum was placed in the vagina. Vaginal cuff noted to be intact, slight area of erythema at the left apex.
The cuff was grasped with Allis clamps. The area of erythema was probed with a size 2 Hegar dilator. This was eventually expanded to a size 4 Hegar dilator. Hemostat used to expand the opening on the vaginal cuff. As the cuff continued to expand and open, slight serosanguineous drainage noted. At this point swabs were obtained for culture and Gram stain. Suction of this area showed slight loculated material.
Foley catheter placed at this time. Next transabdominal ultrasound showed small pocket of fluid in the suprapubic region off to the patient's left. This was palpated with fingers and seen on ultrasound. Hegar dilator probed in this area and more serosanguineous fluid noted. Second swab obtained from this area.
Next a JP drain was placed and sewn to the anterior cuff with silk suture. The vaginal cuff was reapproximated with 2-0 PDS sutures and figure-of-eight stitches. Vaginal cuff noted to be hemostatic and JP drain in position. The drain was hooked up to bulb suction with slight serosanguineous fluid noted.
After the procedure, all instruments were removed from the vagina. Vaginal cuff noted to be hemostatic and urine noted to be clear. The patient tolerated the procedure well. All counts were correct. The patient was taken from the operating room in stable condition after she was cleaned.
The patient will return to her room postoperatively. Plan to monitor drain output and repeat CT scan as needed.
Disposition: PACU - hemodynamically stable.
Condition: stable
Thank you