© Copyright 2025 American Medical Association. All rights reserved.
Transrectal drainage of a pelvic abscess is a medical procedure aimed at alleviating the accumulation of pus within the pelvic cavity, which can occur due to infections or other underlying conditions. This procedure is typically indicated when an abscess is identified through a digital rectal examination, where the physician can palpate the swollen area. The technique involves the insertion of closed thin-curved scissors into the rectum, guided by the physician's index finger, to create a small incision directly into the abscess. This incision allows for the drainage of the infected material, which is crucial for relieving pressure and preventing further complications. In some cases, a drain may be placed to ensure continued drainage and facilitate healing. The procedure is performed under sterile conditions to minimize the risk of infection and is essential for managing pelvic abscesses effectively.
© Copyright 2025 Coding Ahead. All rights reserved.
Transrectal drainage of a pelvic abscess is indicated for the following conditions:
The procedure for transrectal drainage of a pelvic abscess involves several critical steps to ensure effective drainage and patient safety.
After the transrectal drainage procedure, patients may require monitoring for any signs of complications, such as infection or excessive bleeding. It is essential to provide appropriate post-procedure care, which may include pain management and instructions for wound care if an incision was made. Patients should be advised on signs of infection, such as increased pain, fever, or unusual discharge, and instructed to follow up with their healthcare provider as needed. Recovery time may vary depending on the individual and the extent of the abscess, but most patients can expect to resume normal activities within a short period, provided there are no complications.
| Short Descr | DRAINAGE OF PELVIC ABSCESS | Medium Descr | TRANSRECTAL DRAINAGE OF PELVIC ABSCESS | Long Descr | Transrectal drainage of pelvic abscess | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 96 - Other OR lower GI therapeutic procedures |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.