# Incision and drainage Perirectal Abscess



## R1CPC (Apr 8, 2015)

Need help with CPT 

The patient was flipped to the prone position and perineum was prepped and draped in sterile fashion. Final time out was done. Digital rectal examination was done and no mass or any defedts were noted. the anoscope was introduced into the anal canal, there were no inflammatory changes in the anal canal, none that would be significat for Chrohns disease and no internal opening was noted. At this point, a fluctulat area was noted to the right. A cruciate incision was made and approximately 40 mL of pus was extracted. I went ahead and irrigated the area, sent it for cultures and then injected it with amixture of methylene blue and placed a gauze into the vaginal vault to see if there was any leakage into the vagina as this was not comin from the anal canal. Same wa also done looking in the anal canal. No methylene blue was noted in the anal anal or on the gauze into the vaginal cuff. So at this point I irrigated and packed the wound.


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## torifreak12 (Apr 9, 2015)

Hmph . . . so was it a vaginal abscess or a rectal abscess?  If it really was a rectal abscess, it would be 46040, with ICD-9 566.  But if it was a vaginal abscess, it would be 57010 with ICD-9 616.10.  The report sounds a little confusing, though, in terms of where the abscess was drained.


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