Can we code 46040 and 75989 for perirectal abscess drainage.
The patient was placed prone on the CT table. Preliminary CT was
performed with a grid to mark a site for drainage. A right
gluteal was marked, prepped and draped in a sterile fashion. The
area was locally anesthetized with one percent lidocaine. Using
CT guidance, an 18 gauge guiding needle was advanced, positioned
with the tip within the abscess. An Amplatz wire was advanced and
seen coiled within the lesion. The tract was dilated and then an
8.5 Fr Dawson-Mueller catheter was placed. The loop was formed
and locked in place. The catheter was then secured to the skin
with 3-0 prolene. 18cc pus was aspirated. The catheter was
connected to gravity bag drainage. At the end of the procedure a
sterile dressing was applied. Specimen was taken to Pathology at
the end of the procedure for culture and sensitivity.
The patient tolerated the procedure well, and left the department
in stable condition. No immediate complications.
Impression: CT guided drainage of perirectal abscess with 8.5 Fr
catheter. Pus was aspirated and taken to Pathology at the end of
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