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Rectoscopy placement catheter pelvic abscess

  1. Default Rectoscopy placement catheter pelvic abscess
    Medical Coding Books
    I have a rough one here that I am just lost is the op note. Any help would be greatly appreciated...

    The patient was brought to the operating room, placed on the operating table in the supine position. After adequate general endotracheal anesthesia induced the patient was placed in high stirrups. The patient was prepped and draped in the usualy sterile fashion. Digital examination revealed a short Hartman's pouch with a small fistula perhaps 3 to 4mm in diameter. Flexible endoscopy revealed the same with easy passage of the scope into the pelvic abscess where I could see the pigtail catheter which was placed percutaneously. There was some debris in here. there was some granulation tissue. This was dilated slightly and then a large 24 mushroom catheter was placed transrectally through this fistula and into the pelvic cavity. This was then sutured with 2 interrupted 0 Ethibond and 0 Vicryl sutures to the parianal dermis. The wound was irrigated with Clorpactin solution. The patient tolderated the procedure well. There were no complications. Brought to recovery in stable condition.

    Thanks in advance for any help!

  2. #2
    I would code this as 45000 transrectal drainage of a pelvic abscess

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