AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 1; Ask the Editor
Presacral Abscess
This patient has history of complicated diverticulitis, status post sigmoid colectomy with end colostomy, complicated by recurring pelvic abscesses, secondary to the remaining rectal Hartmann cuff. The surgeon performed a proctectomy, and the abscess was drained. The provider documented the abscess as pelvic, intra-abdominal, and presacral. When queried for clarification, the provider listed “Presacral abscess of unknown etiology.” What is the correct code assignment for an internal presacral abscess? ...
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Article Overview
This premium article discusses how a presacral abscess is handled for coding purposes when it appears alongside other pelvic or intra-abdominal abscess documentation. It is intended for coding professionals who need guidance on infection-site classification, documentation interpretation, and related ICD-10-CM assignment considerations.
Why This Topic Matters
Accurate coding of abscess location can affect diagnosis selection and reporting consistency when multiple abdominal or pelvic spaces are involved.
What You Will Learn
- How presacral abscess documentation is addressed in coding
- How related pelvic and intra-abdominal abscess references are considered
- What documentation clarification can mean for diagnosis selection
- How the article frames site-based abscess classification in ICD-10-CM
Who Should Read This
- Medical coders
- Coding auditors
- CDI specialists
- Billing professionals
- Health information management professionals
Codes Discussed
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