# CPT 58823 for Females Only?



## cswift (Oct 16, 2009)

Hello all! I'm having a dispute with my CT Techs as to how to charge a procedure. This patient has many issues, so I am going submit the part that is the center of discussion right not. 
To keep it short, The CT techs think 58823, 75989 are the appropriate charges, however I think 10160, 75989, 10160-59, 75989-59 because 2 abscesses were treated are more accurate based on dictation and guidelines. *On another note, even if the patient is male, can 58823 still be used being that the code does say pelvic abscess with a transrectal approach. I dont see any other verbiage that states 58823 is for women exclusively even though it's under the Ovary section...any input would be great!

Thanks again!

The report in question is as follows... sorry for the extensiveness, but I thought it would be more beneficial to have it for review.

 FINDINGS: A CT scan is performed of the abdomen and pelvis with the
patient prone for localizing purposes. This is performed without
contrast. The four abscess collections identified on the MRI are also
identified on the CT scan. This includes a 2.8-cm collection of fluid
along the superior margin of the right SI joint. This will be drained
with the first drainage catheter. A second abscess is seen deep to the
gluteus maximus muscle on the right, about 8 cm x 5 cm in diameter.
This will be drained with the second abscess drainage catheter. There
is an abscess anterior to the right SI joint within the deep pelvis
about 3.5 cm in diameter. This will not be drained today but I will
bring the patient back tomorrow to try to drain this. Finally, there
is a small perirectal abscess located between the rectum and the
prostate gland slightly to the right of midline measuring about 2.9
cm. This will not be drained today and I do not believe that this can
be easily drained percutaneously.
The first small
collection of fluid above the right SI joint is identified with CT
scan. The skin is prepped with Chloraprep. Lidocaine is used for local
anesthesia. Lidocaine needle is introduced into the abscess which
confirms the presence of pus.  Next, using a single-stick method, an
8-French abscess drainage catheter is inserted into this fluid
collection. I was able to remove about 10 cc of thick pus. The abscess
cavity was irrigated until clear. A small amount of contrast was
The first small
collection of fluid above the right SI joint is identified with CT
scan. The skin is prepped with Chloraprep. Lidocaine is used for local
anesthesia. Lidocaine needle is introduced into the abscess which
confirms the presence of pus.  Next, using a single-stick method, an
8-French abscess drainage catheter is inserted into this fluid
collection. I was able to remove about 10 cc of thick pus. The abscess
cavity was irrigated until clear. A small amount of contrast was


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## ciphermed (Oct 16, 2009)

I've recently heard that denials were coming in for CPT 58823 on male patients.  Although the code descriptor does not include gender in it, the location of the code is in CPT Sub category Female Genital System and then listed under Ovary...Based on that alone I would be reluctant to use that code on male patients without further guidance.

Perhaps CPT 45000, if performed transrectally would be more appropriate for male patients.
No references to cite on this one...

Hope this helps,


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## cswift (Oct 16, 2009)

Thanks for your input. This procedure was simply 2 abscess drainages with the drain tubes left in. So, that is why I advised the CT dept that charging 58823 was not correct. They picked the charge that said pelvic abscess drainage, not paying attention to the patient's gender. Thank goodness for Coders!!!! 

Thanks again!

Candy


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## smwaters (Nov 5, 2009)

Agreed - the common consensus around here is that the Ovarian section means it's a no-no \for males.  We typically will code 49021 for the males when it is the percutaneous drainage because I don't think it's appropriate to use 45000 because it's a transanal incision code.


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