Radiology Coding Alert

Question: How should I code the following report?

Clinical Indication: Abscess formation in the right pelvis and a separate abscess in the left lower quadrant abdomen in a patient with severe diverticulitis.

The patient tolerated conscious sedation well ... with the patient in the CT scanner in the prone position, a pelvic abscess was again localized ... the deep right pelvic abscess was punctured, a wire placed followed by a Rosen wire and a series of dilators and a 14 French tube placed.

The patient was then turned supine on the scanner and localization performed over the LLQ ... Using alcohol-based preparation ... a 19 gauge sheath needle was used to puncture with CT guidance the LLQ abscess ... A large J-wire was placed followed by a Rosen wire and a series of dilators. A tube was placed and pus removed. Each tube secured.

South Carolina Subscriber

Answer: For the percutaneous abscess drainage, you should report 49021 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous).

The appropriate code for the guidance is 75989 (Radiologic guidance [i.e., fluoroscopy, ultrasound or computed tomography], for percutaneous drainage [e.g., abscess, specimen collection], with placement of catheter, radiologic supervision and interpretation).

You should report two units of each.

For the diagnosis codes you'll need to dig a little deeper into the chart. The appropriate code for abscess on the abdominal wall is 682.2 (Other cellulitis and absess; trunk), but if it's in the abdominal cavity, you should report 567.22 (Peritoneal abscess). The most likely diagnosis for the pelvic abscess is also 567.22.