# CPT Code help - incision and drainage of peri rectal abscess



## bill2doc (Jun 22, 2021)

*I hate these... I always go down a rabbit hole.  Any suggestions ?  Thank you!*

Pt was taken to the O.R and placed prone jackknife.. prepped and draped in sterile fashion. IV sedation and general anesthesia instituted. The perianal region was palpated and an area of fluctuance identified, a 20 mL syringe and 18 gauge needle used to find pocket of pus, an incision was made over the fluctuant area , with a stab incision using 15 blade and away from the external sphincters and in line with the circular fibers , with evacuation of 75 ml of pus. A clamp was inserted into the cavity and the septations were broken up.  the area was irrigated copiously and a drain was placed and sutured nylon to the skin. A sterile dressing was placed.


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## maebelle@gmail.com (Jun 22, 2021)

46040?


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## thomas7331 (Jun 22, 2021)

46040 is for a perirectal abscess, but the documentation posted says that is was in 'the perianal region', which would be 46050.  Since the physician also documents 'away from the external sphincters', that also suggests to me this is not perirectal.  I would choose 46050 based on what's here, unless there's additional information available.


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## bill2doc (Jun 23, 2021)

thomas7331 said:


> 46040 is for a perirectal abscess, but the documentation posted says that is was in 'the perianal region', which would be 46050.  Since the physician also documents 'away from the external sphincters', that also suggests to me this is not perirectal.  I would choose 46050 based on what's here, unless there's additional information available.


No other info listed.  Thank you for your reply!


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## bill2doc (Jun 23, 2021)

maebelle@gmail.com said:


> 46040?


I started with that too but wasn't sure.  Thank you for your reply


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