Q&A: Reporting perianal abscess I&D in ICD-10-PCS

Q: We are confused about which body part value in ICD-10-PCS should be captured for an incision and drainage (I&D) of a perianal abscess of the left buttocks because the physician documented both “perianal” and “left buttocks.”

A: First, it’s important to remember that I&D procedures are reported with the root operation Drainage in ICD-10-PCS and this has been confirmed in multiple Coding Clinics (First Quarter 2015, Third Quarter 2015, and Fourth Quarter 2017).

Typically, the prefix “peri” should be assigned to the anatomic location when it precedes a body part if there is no specific body part available. However, according to Coding Clinic, Third Quarter 2018, perianal abscesses are just abscesses superficially located next to the anus and involve the skin and subcutaneous tissues, rather than the anus itself.

The ICD-10-PCS guidelines do state that if the documentation cites a specific body part, then that body part should be assigned and not the body part described as “peri.”  

Since you said the provider documented that the perianal abscess was on the left buttock region, I would advise you to report this as a Drainage of the subcutaneous tissue, applying the guideline to report the deepest layer of the subcutaneous tissue to the body part value left buttock.

This would be reported with ICD-10-PCS code 0J990ZZ (Drainage of buttock subcutaneous tissue and fascia, open approach).

Editor’s note: Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, director of HIM and coding for HCPro, a Simplify Compliance brand, in Middleton, Massachusetts, answered this question.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.