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L02.416
ICD-10-CM
Left Thigh Abscess

Find comprehensive information on Left Thigh Abscess diagnosis, including clinical documentation, ICD-10 codes (L02.411, L02.412, L02.419), medical coding guidelines, treatment options, and healthcare resources. Learn about symptoms, differential diagnosis, and best practices for accurate coding and documentation of a Left Thigh Abscess in medical records. This resource provides valuable insights for healthcare professionals, coders, and clinicians seeking information on Left Thigh Abscess.

Also known as

Thigh Abscess
Abscess of Left Lower Limb

Diagnosis Snapshot

Key Facts
  • Definition : Collection of pus within the left thigh tissues.
  • Clinical Signs : Pain, swelling, redness, warmth, and limited mobility in the left thigh. Fever may be present.
  • Common Settings : Community-acquired, post-surgical, or related to intravenous drug use.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC L02.416 Coding
L02.4

Cutaneous abscess of thigh

Abscess located in the skin of the thigh.

L02.9

Cutaneous abscess, unspecified

Abscess in the skin, but the specific site isn't documented.

M72.609

Abscess of thigh, unspecified

Deep thigh abscess, not otherwise specified.

Code-Specific Guidance

Decision Tree for

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

Is the left thigh abscess cutaneous?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left Thigh Abscess
Cellulitis of Left Thigh
Left Thigh Hematoma

Documentation Best Practices

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

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding left thigh abscess without specifying laterality can lead to claim rejections. Ensure documentation clarity for accurate coding (e.g., L75.01).

  • Missing Etiology

    Lack of documentation specifying the cause of the abscess (e.g., staphylococcal) impacts code selection and reimbursement. CDI should query for details.

  • Superficial vs. Deep

    Insufficient documentation to distinguish between superficial and deep abscesses can lead to inaccurate coding and potential compliance issues. Clarify depth in physician notes.

Clinical Decision Support

Checklist
  • Verify localized swelling, erythema, tenderness in left thigh.
  • Confirm purulent drainage or fluctuance on palpation.
  • Check for fever, leukocytosis, or elevated inflammatory markers.
  • Document size, location, and characteristics of abscess.

Reimbursement and Quality Metrics

Impact Summary
  • Left Thigh Abscess: Reimbursement and Quality Metrics Impact Summary
  • ICD-10: L02.41 (Abscess of buttock and thigh)
  • CPT: Incision and Drainage (e.g., 10060, 10061), dependent on complexity
  • Accurate coding crucial for appropriate MS-DRG assignment and reimbursement.
  • Coding impacts hospital-acquired condition reporting (HAC) if post-op infection develops.
  • Sepsis quality metrics affected if abscess leads to severe sepsis or septic shock.
  • Timely and effective treatment impacts patient satisfaction scores and readmission rates.
  • Proper documentation vital for accurate coding, optimal reimbursement, and quality reporting.

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.

Quick Tips

Practical Coding Tips
  • Code L02.418 for thigh abscess
  • Document abscess location, size
  • Specify if primary or secondary
  • Consider I&D procedure codes
  • Check for cellulitis (L02.4)

Documentation Templates

Patient presents with complaints consistent with a left thigh abscess.  Chief complaint includes localized pain, swelling, erythema, and tenderness to palpation in the left thigh region.  Onset of symptoms is reported as [onset duration, e.g., gradual over the past week, acute onset 2 days ago].  Patient may also report associated symptoms such as fever, chills, malaise, and purulent drainage.  Physical examination reveals an indurated, fluctuant mass measuring approximately [size in cm] located in the [specific location on left thigh, e.g., anterior, medial, posterior, proximal, distal] aspect of the left thigh.  Differential diagnosis includes cellulitis, furuncle, carbuncle, and lymphadenitis.  Skin and soft tissue infection is suspected.  Diagnostic workup may include incision and drainage (IandD), wound culture, and complete blood count (CBC) to assess for leukocytosis.  Ultrasound may be considered to evaluate the extent of the abscess and guide aspiration or drainage procedures.  Treatment plan includes IandD with packing, wound care instructions, and antibiotic therapy with [antibiotic name and dosage] for [duration].  Patient education provided regarding signs and symptoms of infection, wound care management, and follow-up appointment scheduled in [timeframe].  ICD-10 code L02.418 (Abscess of lower leg, left) and CPT code [appropriate code for IandD based on complexity] will be used for billing and coding purposes.  Patient tolerated the procedure well and was discharged in stable condition with follow-up instructions.