Find comprehensive information on perineal abscess diagnosis, including clinical documentation, ICD-10 codes (L02.4, L02.91, and other relevant codes), treatment options, and medical coding guidance. Learn about signs, symptoms, differential diagnosis, and best practices for healthcare professionals managing perineal abscesses. This resource covers key aspects of perineal abscess care, from initial assessment to post-operative management, supporting accurate clinical documentation and coding for optimal patient care.
Also known as
Cutaneous abscess, furuncle, carbuncle
Covers skin infections like abscesses, boils, and carbuncles.
Diseases of the genitourinary system
Includes various genitourinary conditions, some potentially related to perineal abscesses.
Diseases of anus and rectum
Encompasses anorectal diseases that might manifest with perineal involvement.
When to use each related code
| Description |
|---|
| Perineal Abscess |
| Anorectal Abscess |
| Ischiorectal Abscess |
Coding perineal abscess without specifying anatomical site (e.g., scrotum, vulva) leads to coding ambiguity and claim denials.
Lack of clear documentation linking perineal abscess to underlying cause (e.g., Bartholin gland cyst, hidradenitis) impacts accurate code assignment.
Incorrect sequencing for complicated perineal abscess cases with associated cellulitis or systemic infection affects reimbursement and quality metrics.
Patient presents with complaints consistent with a perineal abscess. Symptoms include perineal pain, swelling, tenderness, erythema, and possible purulent drainage. The patient may also report fever, chills, malaise, and difficulty with defecation or urination. Physical examination reveals an indurated, fluctuant mass in the perineal region. Differential diagnoses considered include Bartholin cyst, pilonidal cyst, hidradenitis suppurativa, and anal fistula. Diagnosis of perineal abscess is confirmed based on clinical presentation and physical exam findings. Laboratory tests such as a complete blood count (CBC) with differential and blood cultures may be obtained to evaluate for systemic infection. Imaging studies such as ultrasound or CT scan may be considered if there is concern for deep or complex abscesses. Treatment plan includes incision and drainage of the abscess, which may be performed under local anesthesia or in the operating room depending on the size and complexity of the abscess. Wound care instructions will be provided, including regular sitz baths and dressing changes. Antibiotics may be prescribed for patients with significant cellulitis, systemic symptoms, or immunocompromising conditions. Patient education will be provided on proper hygiene, wound care, and follow-up appointments. ICD-10 code L02.41 (Cutaneous abscess of perineum) and CPT codes for incision and drainage (e.g., 10060, 10061) will be used for billing and coding purposes. Follow-up care will be arranged to monitor healing and assess for any complications such as recurrence or fistula formation.