# perirectal abscess



## Shirleybala

Hello:
Can we code 46040 and 75989 for perirectal abscess drainage.

      The patient was placed prone on the CT table.  Preliminary CT was
       performed with a grid to mark a site for drainage.  A right
       gluteal was marked, prepped and draped in a sterile fashion.  The
       area was locally anesthetized with one percent lidocaine.  Using
       CT guidance, an 18 gauge guiding needle was advanced,  positioned
       with the tip within the abscess.  An Amplatz wire was advanced and
       seen coiled within the lesion.  The tract was dilated and then an
       8.5  Fr Dawson-Mueller catheter was placed.    The loop was formed
       and locked in place.  The catheter was then secured to the skin
       with 3-0 prolene.  18cc pus was aspirated.  The catheter was
       connected to gravity bag drainage.  At the end of the procedure a
       sterile dressing was applied.  Specimen was taken to Pathology at
       the end of the procedure for culture and sensitivity.

       The patient tolerated the procedure well, and left the department
       in stable condition.  No immediate complications.

       Impression: CT guided drainage of perirectal abscess with 8.5  Fr
       catheter.  Pus was aspirated and taken to Pathology at the end of
       the procedure.


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## MLS2

I agree with 75989/46040


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## dhuston

46040 is for incision and drainage, you have a percutaneous drainage.  Perirectal abscess would be 49061 retroperitoneal drainage + 75989 for the guidance.

Diane Huston, CPC,RCC


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## Carlyle Diaz

*Retroperitoneal*

Makes sense. Retroperitoneal means outside the peritoneum.


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## sfeazel

Actually I think retroperitoneal means behind and its the peritoneal which is the abdominal cavity.


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## sfeazel

Actually I think retroperitoneal means behind and its the peritoneal which is the abdominal cavity. Not perineum


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