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K65.1
ICD-10-CM
Pelvic Abscess

Find comprehensive information on pelvic abscess diagnosis, including clinical documentation, ICD-10 codes (N73.4), medical coding guidelines, and differential diagnosis. Learn about symptoms, treatment options, and healthcare best practices for managing pelvic abscesses. This resource provides valuable insights for physicians, nurses, and other healthcare professionals involved in the diagnosis and treatment of this condition. Explore relevant medical terminology, diagnostic criteria, and coding resources for accurate and efficient clinical documentation.

Also known as

Abdominopelvic Abscess
Intra-abdominal Abscess

Diagnosis Snapshot

Key Facts
  • Definition : Pus collection in the pelvic cavity, often from infection.
  • Clinical Signs : Lower abdominal pain, fever, vaginal discharge, painful urination.
  • Common Settings : Post-surgery, postpartum, PID, ruptured appendix.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC K65.1 Coding
N75.0-N75.9

Female pelvic inflammatory disease

Inflammatory conditions of female pelvic organs, often leading to abscesses.

K65.0-K65.9

Peritonitis

Inflammation of the peritoneum, which can be caused by a ruptured pelvic abscess.

L08.81-L08.81

Other local infections of skin and subcutaneous tissue of lower limbs

Infections spreading from a pelvic abscess may involve the lower limbs.

Code-Specific Guidance

Decision Tree for

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

Is the pelvic abscess postpartum?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Pelvic Abscess
Tubo-Ovarian Abscess
Appendiceal Abscess

Documentation Best Practices

Documentation Checklist
  • Document abscess location (e.g., tubo-ovarian, cul-de-sac)
  • Pelvic abscess size and characteristics documented
  • Symptoms/signs: fever, chills, pelvic pain, vaginal discharge
  • Imaging results confirming pelvic abscess (e.g., ultrasound, CT)
  • Lab results (e.g., WBC, CRP) supporting infection diagnosis

Mitigation Tips

Best Practices
  • Document abscess location, size, and etiology for accurate ICD-10 coding (N73.x).
  • CDI: Query for source of infection to specify pelvic abscess type for optimal DRG assignment.
  • Ensure complete pelvic exam documentation, including imaging results, for compliant billing.
  • Labs, cultures, and treatment details support diagnosis and justify medical necessity for payers.
  • Timely follow-up documentation reflects appropriate care and reduces healthcare compliance risks.

Clinical Decision Support

Checklist
  • Verify pelvic pain, tenderness, or mass (ICD-10 N73.4)
  • Confirm fever or elevated inflammatory markers (patient safety)
  • Image with CT/US to visualize abscess (clinical documentation)
  • Check for gynecological/GI source (accurate coding)

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 primary abscess site
  • Specify abscess etiology
  • Document drainage procedures
  • Query physician for clarity
  • Check ICD-10 guidelines

Documentation Templates

Patient presents with complaints consistent with pelvic abscess, including pelvic pain, lower abdominal pain, vaginal discharge, fever, chills, and malaise.  Physical examination reveals tenderness to palpation in the lower abdomen and pelvic region, possible guarding and rebound tenderness.  Vaginal examination may demonstrate cervical motion tenderness, adnexal mass, or fullness.  Differential diagnosis includes appendicitis, ovarian cyst, ectopic pregnancy, inflammatory bowel disease, and sexually transmitted infections such as pelvic inflammatory disease (PID).  Laboratory studies including complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may indicate elevated inflammatory markers.  Imaging studies such as pelvic ultrasound, CT scan of the abdomen and pelvis, or MRI may be indicated to confirm the presence, size, and location of the abscess.  Treatment options for pelvic abscess include intravenous antibiotics, percutaneous drainage guided by imaging, or surgical drainage depending on the size and location of the abscess and patient stability.  Patient education provided regarding the diagnosis, treatment plan, and potential complications including sepsis.  Follow-up care scheduled to monitor response to treatment and assess for resolution of the abscess.  ICD-10 code N73.5 (Pelvic abscess, female) or N73.6 (Pelvic abscess, male) applicable.  CPT codes for procedures performed, such as drainage, will be documented separately.