presacral abscess drainage- transgluteal approach

chembree

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CT-GUIDED DRAINAGE:

INDICATION: Persistent presacral abscess status post colonic surgery in
2005.

TECHNIQUE: After written informed consent was obtained, under sterile
conditions after administration of local anesthetic, with the patient in
the prone position and after the patient received IV Versed and fentanyl
given intravenously for a total of 45 minutes during the procedure,
using a right oblique transgluteal approach into the small fluid
collection in the presacral space, a 21-gauge needle was advanced
obtaining a small amount of thin clear yellow fluid. Next, a guidewire
was inserted. This allowed dilatation up to 8-French. Next, an 8-French
pigtail drainage catheter was placed into the collection. An admixture
of fluid and blood was obtained. The rind of this collection is quite
scarred and it required dilators to allow placement of the 8-French
drain. Once the drain was in position it was secured to the patient's
skin. The patient tolerated the procedure well. 2-0 silk was utilized to
anchor the suture in place. It was connected to a bulb suction gravity
drainage bag.

IMPRESSION:

CT-guided presacral longstanding fluid collection abscess type drainage
without complication. Patient will be seen in 10 days with a repeat CT
of the pelvis with contrast and hopefully will be able to remove the
catheter shortly afterwards.

Can anyone offer any guidance for this procedure? I am looking at 49061, 75989. I also see 45000...

I know 58823 is listed in the CPT Expert book as a female only code and this is a male patient.
 
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sashka

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49021 is for a pelvic abscess drainage

49061/75989 is for retroperitoneal abscess drainage. Code 49021/75989 describes pelvic abscess drainage by a trans-abdominal or trans-sacral notch approach. I'd code49021/75989.
 

chembree

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49061/75989 is for retroperitoneal abscess drainage. Code 49021/75989 describes pelvic abscess drainage by a trans-abdominal or trans-sacral notch approach. I'd code49021/75989.
Can you give me clarification for your code recommendation of 49021. I do not see it listed as trans-sacral notch approach? Also, the patient in the report has pre-sacral abscess and this code describes drainage of the peritoneal or peritonitis which is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs.
Do you have a recourse that gives more guidance than the CPT book that you may be referencing?
 
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