Abdominal Abscess I&D
Medical Specialty: Gastroenterology
Description: Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue, and muscle, then removal of foreign body.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Abdominal wall abscess.
POSTOPERATIVE DIAGNOSIS: Abdominal wall abscess.
PROCEDURE: Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue,e and muscle, then removal of foreign body.
ANESTHESIA: LMA.
INDICATIONS:
Patient is a pleasant 60-year-old gentleman who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration. Came in approximately 36 hours ago with pain across his lower abdomen. CT scan demonstrated the presence of an abscess beneath the incision. I recommended to the patient that he undergo the above-named procedure. Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him, and he agreed to surgery.
FINDINGS:
The patient was found to have an abscess that went down to the level of the fascia. The anterior layer of the fascia was fibrinous, and some portions were necrotic. This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound; these were removed as well.
TECHNIQUE:
Patient was identified, then taken into the operating room, where, after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion. The wound opening where it was draining was explored using a curette. The extent of the wound was marked with a marking pen, and using the Bovie cautery, the abscess was opened and drained. I then noted that there was a significant amount of undermining. These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia. The wound was irrigated; cultures were sent prior to irrigation, and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze. A dressing was applied. The finished wound size was 9.0 x 5.3 x 5.2 cm in size. Patient tolerated the procedure well. Dressing was applied, and he was taken to the recovery room in stable condition.
SCENARIO OVERVIEW (Coding Context)
- Patient: 60-year-old male
- Specialty: Gastroenterology / General Surgery
- Setting: Operating room
- Condition: Postoperative abdominal wall abscess with necrotic tissue and retained sutures
- Procedures performed:
- Incision and drainage of abscess
- Excisional debridement of skin, subcutaneous tissue, muscle, and fascia
- Removal of retained suture material (foreign body)
- Wound size: 9.0 × 5.3 × 5.2 cm
- Closure: Left open, packed with gauze
ICD-10-CM DIAGNOSIS CODES
L02.211 – Cutaneous abscess of abdominal wall
Rationale:
- Both the preoperative and postoperative diagnoses are documented as abdominal wall abscess
- The abscess extended to the fascia, confirming severity
- This is the primary diagnosis driving the procedure
Z18.9 – Retained foreign body fragments, unspecified material
Rationale:
- Operative findings document multiple retained sutures within the wound
- These were actively removed during the procedure
- Appropriate as a secondary diagnosis to explain the medical necessity of foreign body removal
CPT PROCEDURE CODES
11043 – Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue); first 20 sq cm or less
Rationale:
- Documentation clearly states excisional debridement
- Tissue levels removed include:
- Skin
- Subcutaneous tissue
- Muscle
- Fascia
- Coding is driven by the deepest level of debrided tissue, which is muscle/fascia
- Although the wound surface area exceeds 20 sq cm, many payers accept reporting only the base code unless add-on units are clearly supported and payer-allowed
10121 – Incision and removal of foreign body, complicated
Rationale:
- Retained sutures were embedded within the wound
- Removal required surgical exploration and was not incidental
- Meets criteria for complicated foreign body removal
- Not bundled into debridement because:
- The foreign body removal was distinct
- It addressed a separate clinical issue
CODES NOT REPORTED (WITH REASONS)
- 10060 / 10061 (Simple or complicated abscess I&D)
Not appropriate due to deep excisional debridement of muscle and fascia
- 11042 (Subcutaneous debridement only)
Incorrect because the muscle and fascia were debrided
- Wound repair or closure codes
Not reported because the wound was left open and packed
- Separate I&D code
Incision and drainage are bundled into the debridement when performed together at the same site
FINAL CODING SUMMARY
| Type | Code | Description |
| ICD-10-CM | L02.211 | Cutaneous abscess of the abdominal wall |
| ICD-10-CM | Z18.9 | Retained foreign body fragments |
| CPT | 11043 | Excisional debridement of muscle/fascia |
| CPT | 10121 | Complicated foreign body removal |
KEY CODING PRINCIPLES HIGHLIGHTED
- Debridement coding is based on the deepest tissue removed
- Excisional debridement must be clearly documented, as it is in this report
- I&D is not separately reportable when inherent to debridement
- Foreign body removal may be separately coded when medically necessary and distinct