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Drainage using Trans-Gluteal Approach

  1. #1
    Default Drainage using Trans-Gluteal Approach
    Medical Coding Books
    What do I use to code a CT guided Trans-Gluteal approach for a Pelvis Fluid Collection? report:

    Survey CT imaging of the pelvis demonstrates the collection corresponding to that seen on prior CT. The left buttock was prepped and draped in usual steril fashion. Following the administration of conscious sedation and local anesthesia and under CT guidance, an 19 gauge needle was advanced into the collection using a trans-gluteal approach. upon aspiration of purulent material, a .035 inch heavy duty wire was advanced and looped within the collection. Dilatation of the puncture was performed and a 10 french self retaining catheter placed. 20cc's of fluid was aspirated and sent for laboratory evaluation including culture. The catheter was secured to the skin and attached to JP drainage.

    I was thinking 49021/75989 but can I use that for any pelvic abscess drainage? I know I can't use 58823.

  2. #2
    I think 75989/49021 would be correct for this case. it was a percutaneous entry and cath. placed to drain a pelvic fluid collection.

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