We have a physician who took a patient to the OR for a large pelvic mass (left of the rectal and anal canal with extensive suprasphincteric component and presacral component). There was an opening below the sacrum that was draining. He did a digital rectal exam and with digital pressure he was able to drain purulent material so he went in through the opening and placed a Malecot catheter for drainage. Since there was not an incision done how would this be coded? The closest thing we could come up with was 58823 but it is a male and that is a female code. Any suggestions would be greatly appreciated.
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