Anesthesia Coding Alert

Question: What code would we use for a CT-guided irrigation and drainage of a psoas muscle abscess?

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Answer: For a deep abscess, choose 26990 (Incision and drainage, pelvis or hip joint area; deep abscess or hematoma). For a more superficial procedure, report 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, curaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single).

Definition: The psoas muscle originates on the lumbar vertebrae and attaches to the femur, so you'll want to choose a code related to procedures in the hip region. You'll also need to know how deeply the physician went to treat the abscess because the psoas muscle is divided into superficial and deep areas.

CPT defines "superficial" versus "deep" in the introductory notes before repair/closure codes (prior to code 12001). A superficial repair primarily involves the epidermis or dermis and subcutaneous tissue. A deep repair is considered "intermediate" and involves layered closure of one or more of the deeper layers of subcutaneous tissue and superficial fascia.

Anesthesia choice: You'll code differently if your physician provided anesthesia for another provider to perform the procedure. If the physician completed drainage through an open incision, report 01210 (Anesthesia for open procedures involving hip joint; not otherwise specified). For drainage not through an open incision, choose 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified) for access through the posterior trunk. Report 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) for anterior access.