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L02.31
ICD-10-CM
Buttock Abscess

Learn about buttock abscess diagnosis, including clinical documentation, medical coding, and treatment. Find information on gluteal abscesses, boils on the buttock, and furuncles of the buttock. This resource covers healthcare best practices for identifying and managing a buttock abscess.

Also known as

Gluteal Abscess
Boil on Buttock
Furuncle of Buttock
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : A localized collection of pus within the buttock tissues.
  • Clinical Signs : Pain, swelling, redness, warmth, and tenderness on the buttock. Fever may be present.
  • Common Settings : Community-acquired, often associated with MRSA. Seen in outpatient and emergency room settings.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC L02.31 Coding
L02.4

Cutaneous abscess of buttock

Abscess located on the buttock skin.

L02.9

Cutaneous abscess, unspecified

Abscess of the skin without a specific location.

L02

Cutaneous abscess, furuncle and carbuncle

Localized skin infections with pus formation.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the buttock abscess related to hidradenitis suppurativa?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Infection with pus in buttock tissues.
Infection of hair follicle, often on buttock.
Deeper buttock infection, possibly involving muscle.

Documentation Best Practices

Documentation Checklist
  • Document abscess location (L/R, gluteal, ischiorectal).
  • Describe abscess size (cm), appearance (fluctuant, erythematous).
  • Note any pain, tenderness, fever, or other symptoms.
  • Record associated conditions (hidradenitis, diabetes).
  • Document I&D procedure, if performed (incision size, drainage).

Coding and Audit Risks

Common Risks
  • Specificity of Coding

    Coding buttock abscess requires distinguishing between simple abscess (L02.41) and complex/deep tissue infection (e.g., M72.6). Miscoding impacts reimbursement and quality metrics.

  • Documentation Clarity

    Insufficient documentation of abscess location, size, depth, and causative organism can lead to coding errors and claim denials. CDI can improve documentation specificity.

  • Sepsis Risk Assessment

    Untreated buttock abscesses can progress to sepsis. Coding should reflect sepsis severity (A41.9) for accurate risk adjustment and appropriate care management.

Mitigation Tips

Best Practices
  • Proper ICD-10 coding (L02.4*) for buttock abscess documentation.
  • Thorough CDI: Document abscess size, location, and causative organism.
  • Ensure compliance with sterile procedures for incision and drainage.
  • Timely wound care and antibiotic stewardship to prevent recurrence.
  • Patient education: Hygiene, proper cleansing to minimize future abscesses.

Clinical Decision Support

Checklist
  • Confirm localized buttock swelling, pain, redness (ICD-10 L02.4)
  • Rule out pilonidal cyst (ICD-10 L05.0) via exam/imaging
  • Assess for fever, systemic symptoms (sepsis risk)
  • Document abscess size, location, and fluctuance
  • Consider MRSA risk factors (diabetes, IV drug use)

Reimbursement and Quality Metrics

Impact Summary
  • Medical billing: Accurate ICD-10 coding (L02.4XX) crucial for buttock abscess reimbursement.
  • Coding accuracy: Miscoding as cyst or cellulitis impacts reimbursement and quality metrics.
  • Hospital reporting: Buttock abscess data affects infection control and antibiotic stewardship metrics.
  • Reimbursement impact: Proper documentation of size, depth, and complexity justifies higher-level codes.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the best evidence-based antibiotic treatment options for a complicated buttock abscess requiring incision and drainage in a patient with no known drug allergies?

A: Incision and drainage is the cornerstone of treatment for a complicated buttock abscess. Antibiotic therapy is often indicated in complicated cases, such as those involving deep tissue infection, systemic symptoms (fever, chills), cellulitis extending beyond the abscess, or immunocompromised patients. For patients with no known drug allergies, empirically recommended first-line options include trimethoprim-sulfamethoxazole (TMP-SMX) for coverage of methicillin-resistant *Staphylococcus aureus* (MRSA), or doxycycline. Alternatives include clindamycin or linezolid, particularly if concern exists for community-acquired MRSA. Vancomycin should be reserved for severe infections or those not responding to other therapies. Culture and sensitivity results should guide subsequent antibiotic adjustments if necessary. Consider implementing antimicrobial stewardship principles when prescribing antibiotics for buttock abscesses to minimize the development of resistance. Explore how local resistance patterns can influence antibiotic choices.

Q: How can I differentiate between a simple buttock abscess, a furuncle, a carbuncle, and a pilonidal cyst during physical examination?

A: Differentiating these conditions requires careful examination. A simple buttock abscess typically presents as a localized, fluctuant, tender mass filled with pus. A furuncle (boil) is a smaller, more superficial infection involving a hair follicle, often with a central pustule. A carbuncle involves multiple interconnected furuncles forming a deeper, more extensive infection. A pilonidal cyst occurs in the sacrococcygeal cleft, usually presenting as a chronic sinus tract with recurring infection or abscess formation. Key differentiating features include location (pilonidal cyst specifically in the intergluteal cleft), depth of involvement (carbuncles deeper than furuncles), and presence of interconnected lesions (carbuncles). Learn more about the appropriate imaging modalities for complex or deep buttock abscesses if the diagnosis is unclear based on physical exam findings.

Quick Tips

Practical Coding Tips
  • Code L02.418 for buttock abscess
  • Document abscess size, depth
  • Rule out hidradenitis (L73.2)
  • Consider cellulitis (L03.118)
  • Check for systemic infection

Documentation Templates

Patient presents with complaints consistent with a buttock abscess, also referred to as a gluteal abscess, boil on the buttock, or furuncle of the buttock.  The patient reports localized pain, swelling, redness, and tenderness in the gluteal region.  Physical examination reveals an erythematous, indurated, fluctuant mass on the buttock.  Differential diagnoses considered include cellulitis, pilonidal cyst, and hidradenitis suppurativa.  Based on the clinical presentation and physical exam findings, the diagnosis of buttock abscess is confirmed.  Treatment plan includes incision and drainage of the abscess, wound packing, and prescription for antibiotics to address the infection and prevent recurrence.  Patient education provided on proper wound care, hygiene practices, and follow-up appointments.  ICD-10 code L02.41 will be used for medical billing and coding purposes.  The prognosis for complete resolution is good with appropriate treatment and patient compliance.