2025 CPT code 45000
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Transrectal drainage of a pelvic abscess.
Modifiers may be applicable to 45000 to indicate specific circumstances of the procedure, such as increased procedural services (22), reduced services (52), or multiple procedures (51).Refer to current CPT coding guidelines for appropriate modifier usage.
Medical necessity for 45000 is established when a symptomatic pelvic abscess is present and requires drainage.The medical record should clearly document the patient's signs and symptoms, such as pain, fever, and the presence of the abscess confirmed through imaging.
The physician prepares the patient, identifies the abscess location (possibly with a proctoscope), makes the incision, irrigates and drains the abscess, and leaves the incision open for further drainage.
In simple words: The doctor drains a pus-filled pocket (abscess) in the pelvis through the rectum.This helps relieve pain and stop the infection from spreading.
Drainage of a pelvic abscess using a transrectal approach. This procedure involves making an incision through the rectum into the abscess cavity to irrigate and drain the pus. The incision is typically left open for continued drainage.
Example 1: A patient presents with persistent pelvic pain and fever. Imaging reveals a pelvic abscess. Transrectal drainage is performed to evacuate the abscess and resolve the infection., A postoperative patient develops a pelvic abscess as a complication. Transrectal drainage is chosen as a minimally invasive approach to address the abscess., A patient with a known pelvic abscess is experiencing worsening symptoms.Transrectal drainage is performed to alleviate pain and prevent further complications like sepsis.
Documentation should include the size and location of the abscess, the approach used, the amount of drainage, and any complications encountered. The patient's presenting symptoms and the medical necessity for the procedure should also be documented.
- Revenue Code: P5E - AMBULATORY PROCEDURES - OTHER
- Specialties:General Surgery, Colon and Rectal Surgery,Interventional Radiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center