Surgical Coding Example - CT Guided Drain for Abscess The report below describes a patient undergoing a guided drain for abscess. The entire procedure has been documented in detail, describing the step-by-step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.

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By: Sheila Haynes – Coding and Compliance Manager


Indication: Abscess

Procedure: CT Guided Retroperitoneal Peripancreatic Fluid Collection Drainage

Indications: Status post bowel resection. History of pancreatic cancer and metastatic disease. The patient has persistent leukocytosis. Ct image demonstrates a rim-enhancing mass concerning for abscess.

Medications: See nursing MAR. Moderate sedation was monitored by the Radiology nursing team

Complications: None

Procedure: Written informed consent was obtained in a SPARQ conference with the patient. The patient was prepped and draped in the usual manner. Using local anesthetic and non-contrast enhanced CT guidance a blunt tipped Hawkins needle was advanced into the fluid collection from a posterolateral retroperitoneal approach. Purulent fluid was aspirated and sent to the laboratory for further evaluation. Over a guidewire serial dilatation was performed and a 10 French multipurpose drainage catheter was advanced into the collection using CT guidance. The catheter was aspirated and placed to suction bag drainage. The catheter was sutured in place. A completion CT was obtained

Findings: there is a fluid collection in the peripancreatic retroperitoneum. A total of 40mL of purulent fluid was aspirated. A 10 French drainage catheter was positioned in the collection.

Impression: Successful CT guided drainage of retroperitoneal peripancreatic fluid collection with removal of 40mL of purulent fluid.

Correct CPT and ICD-10 Codes:
CPT: 49406

  • 49406: Image-guided collection drainage by catheter (e.g. abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous

ICD-10: K68.11, Z85.07

  • K68.11: Postprocedural retroperitoneal abscess
  • Z85.07: Personal History of malignant neoplasm of pancreas