Wiki pelvic abscess - how to code?

[rgrimes]

Patient had pelvic abscess - Doctor did inscision into lower body cavity. An abscess was digitally entered in the left side of the pelvis. Creamy thich yellow pus was encountered.....later in dictation, Dr went on to do a left salpingectomy.

Does this qualify as a 49020 even though Dr didn't incise the abcess?

Ruth Ann

 

[preserene]

Whether did the incision intentionally or accidentally, the abscess is opened, meaning, without "cutting' into its surface, cannot be drained.So it is classed under "INCISION" .The specificity of coding is for DRAINAGEof peritoneal abscess or localized peritonitis exclusive of appendicular. So any other abscess in the pelvis -be it PID abscess or ovarian or tubal peritubal whatever, all fall into these cateogory. There is no separate coding with the tube/ovary(abdominal) open method.So this 49020 is the most appropriate cpt coding. We can support it with ICD code 614.4. Then, for Salpingectomy uni/bilateral 58700 (Separate procedure)