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L02.31
ICD-10-CM
Left Buttock Abscess

Find comprehensive information on Left Buttock Abscess diagnosis, including clinical documentation, ICD-10 codes (L02.62, L02.61, L02.60), medical coding guidelines, healthcare best practices, and treatment options. Learn about symptoms, causes, and differential diagnosis for Left Buttock Abscess to improve patient care and ensure accurate medical recordkeeping. This resource offers valuable insights for physicians, nurses, medical coders, and other healthcare professionals.

Also known as

Gluteal Abscess
Buttock Boil

Diagnosis Snapshot

Key Facts
  • Definition : Collection of pus within the left buttock tissues.
  • Clinical Signs : Pain, swelling, redness, warmth, and tenderness in the left buttock. Fever may occur.
  • Common Settings : Community-acquired, healthcare-associated (e.g., after injections).

Related ICD-10 Code Ranges

Complete code families applicable to AAPC L02.31 Coding
L02

Cutaneous abscess, furuncle, and carbuncle

Covers skin infections like abscesses, boils, and carbuncles.

L00-L08

Infections of the skin and subcutaneous tissue

Encompasses various skin and tissue infections, including abscesses.

M79.0

Inflammatory disorders of soft tissue

Includes inflammation not elsewhere classified like buttock abscess.

Code-Specific Guidance

Decision Tree for

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

Is the left buttock abscess related to a pilonidal cyst?

  • Yes

    Code L05.01: Pilonidal cyst with abscess, buttock

  • No

    Is the abscess cutaneous?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left buttock abscess
Right buttock abscess
Pelvic abscess

Documentation Best Practices

Documentation Checklist
  • Document abscess location: left buttock
  • Describe abscess characteristics (size, appearance)
  • Note any associated symptoms (pain, fever)
  • Document diagnostic methods (physical exam, imaging)
  • Record treatment plan (incision and drainage, antibiotics)

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding left buttock abscess without specifying laterality can lead to claim rejection or downcoding. Accurate documentation is crucial for proper reimbursement.

  • Missing Etiology

    Lack of documentation specifying the cause of the abscess (e.g., infection, trauma) may impact coding accuracy and CDI specialist queries.

  • Depth Unspecified

    Failing to document the depth of the abscess (e.g., subcutaneous, intramuscular) can affect code selection and lead to audit discrepancies.

Mitigation Tips

Best Practices
  • Document abscess location, size, and appearance for accurate ICD-10 coding (L02.41).
  • Ensure CDI captures complete clinical picture for appropriate MS-DRG assignment.
  • Follow proper sterile technique for IAD prevention, reducing infection risk.
  • Timely incision and drainage with appropriate antibiotic therapy per guidelines.
  • Thorough documentation supports medical necessity and ensures compliance.

Clinical Decision Support

Checklist
  • Confirm localized buttock pain, swelling, redness
  • Palpate for fluctuance, tenderness in left buttock
  • Check for fever, elevated WBC count (if available)
  • Document abscess size, location, and characteristics
  • Consider imaging (ultrasound) if diagnosis uncertain

Reimbursement and Quality Metrics

Impact Summary
  • Left Buttock Abscess: Reimbursement and Quality Metrics Impact Summary
  • ICD-10 L02.41 impacts MS-DRG assignment and reimbursement.
  • Coding accuracy crucial for appropriate payment and CDI initiatives.
  • Hospital reporting of abscesses affects quality metrics and public health data.
  • Proper documentation key for accurate coding and optimal reimbursement.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code L02.415 buttock abscess
  • Document abscess location, size
  • Query physician if unclear
  • Consider I&D procedure codes
  • Check for systemic infection codes

Documentation Templates

Patient presents with complaints consistent with a left buttock abscess.  Symptoms include localized pain, swelling, erythema, and tenderness to palpation in the left gluteal region.  Onset of symptoms reported as [duration].  Patient may also report fever, chills, malaise, and purulent drainage.  Physical examination reveals an indurated, fluctuant mass on the left buttock, possibly with overlying skin changes such as warmth and increased vascularity.  Differential diagnosis includes furuncle, carbuncle, cellulitis, pilonidal cyst, and hidradenitis suppurativa.  Diagnosis of left buttock abscess confirmed based on clinical presentation and physical examination findings.  Treatment plan includes incision and drainage of the abscess, packing with iodoform gauze, and wound care instructions.  Patient education provided regarding proper hygiene, wound dressing changes, and signs of infection.  Antibiotic therapy may be considered based on severity of infection, presence of systemic symptoms, and patient comorbidities.  Follow-up appointment scheduled for wound check and dressing change in [duration].  ICD-10 code L02.411, Left buttock abscess, is documented for billing and coding purposes.  Patient advised to return to clinic or seek emergency medical attention if symptoms worsen or new symptoms develop.