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perirectal abscess

  1. Default perirectal abscess
    Exam Training Packages
    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
    the procedure.

  2. #2
    I agree with 75989/46040

  3. Default
    46040 is for incision and drainage, you have a percutaneous drainage. Perirectal abscess would be 49061 retroperitoneal drainage + 75989 for the guidance.

    Diane Huston, CPC,RCC

  4. Default Retroperitoneal
    Makes sense. Retroperitoneal means outside the peritoneum.
    Last edited by Carlyle Diaz; 05-23-2013 at 09:59 AM.

  5. Default
    Actually I think retroperitoneal means behind and its the peritoneal which is the abdominal cavity.

  6. Default
    Actually I think retroperitoneal means behind and its the peritoneal which is the abdominal cavity. Not perineum

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