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L02.31
ICD-10-CM
Right Buttock Abscess

Find information on right buttock abscess diagnosis, including clinical documentation, ICD-10 codes (L02.411, L02.412, L02.419), treatment options, and healthcare guidance. Learn about symptoms, causes, and differential diagnoses related to a right gluteal abscess. This resource provides essential information for medical professionals, coders, and patients seeking to understand right buttock abscesses.

Also known as

Gluteal Abscess
Buttock Boil

Diagnosis Snapshot

Key Facts
  • Definition : Collection of pus within the right buttock tissues.
  • Clinical Signs : Pain, swelling, redness, warmth, tenderness, and possible fever.
  • Common Settings : Community-acquired, healthcare-associated, from injections or trauma.

Related ICD-10 Code Ranges

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

Cutaneous abscess of buttock

Abscess located in the skin of the buttock region.

L02.9

Cutaneous abscess, unspecified

Abscess in the skin, without a more specific location given.

M72.6

Enthesopathy of gluteal region

Disorder where tendons/ligaments attach to the bone in the buttock, possibly related to deep abscess.

Code-Specific Guidance

Decision Tree for

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

Is the abscess related to a pilonidal cyst?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right buttock abscess
Pelvic abscess
Pilonidal cyst/abscess

Documentation Best Practices

Documentation Checklist
  • Document abscess location: right buttock
  • Describe abscess characteristics: size, color, drainage
  • Note signs/symptoms: pain, swelling, fever
  • Record any performed procedures: I&D
  • Specify diagnosis: right buttock abscess ICD-10 code

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding right buttock abscess without specifying laterality can lead to claim rejection. Use L89.011 for right side.

  • Missing Anatomical Site

    Lack of specific anatomical location within buttock (e.g., ischiorectal) may impact reimbursement. Ensure proper documentation.

  • Incorrect Code for Complication

    Using L02.418 (abscess of buttock) for post-op/traumatic abscess may be incorrect. L02 category codes are for skin/subcutaneous tissue infections, not necessarily abscesses. Query physician for clarification if needed.

Mitigation Tips

Best Practices
  • Document abscess size, location, and appearance for accurate ICD-10 coding (L02.41).
  • CDI: Query physician for complete documentation of etiology, like MRSA, for proper coding.
  • Ensure appropriate debridement and drainage procedures are documented for compliance.
  • For recurring abscesses, document patient education on hygiene and prevention strategies.
  • Monitor and document antibiotic therapy and response for optimal patient care and coding.

Clinical Decision Support

Checklist
  • Confirm localized buttock pain, swelling, erythema
  • Palpate for fluctuance, tenderness, induration
  • Order imaging (ultrasound/CT) to confirm abscess
  • Document size, location, depth of the abscess

Reimbursement and Quality Metrics

Impact Summary
  • Right buttock abscess reimbursement impacts coding accuracy for ICD-10 L02.41 and CPT 10060/10061 affecting hospital reporting.
  • Accurate coding maximizes reimbursement for buttock abscess I&D, impacting case mix index and hospital quality metrics.
  • Sepsis risk adjustment with right buttock abscess diagnosis impacts reimbursement and quality scores for hospital-acquired conditions.
  • Timely documentation and coding of buttock abscess impacts MS-DRG assignment and hospital reimbursement, affecting financial performance.

Streamline Your Medical Coding

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Documentation Templates

Patient presents with complaints consistent with a right buttock abscess.  Symptoms include localized pain, swelling, erythema, and tenderness to palpation in the right gluteal region.  The patient may also report fever, chills, and malaise.  On examination, a fluctuant mass may be palpable.  Differential diagnosis includes furuncle, carbuncle, cellulitis, pilonidal cyst, and hidradenitis suppurativa.  Diagnosis of right buttock abscess is confirmed by physical examination findings.  Treatment plan includes incision and drainage of the abscess, packing the wound with iodoform gauze, and prescribing appropriate antibiotic therapy such as cephalexin or clindamycin to address the infection and prevent recurrence.  Patient education provided on wound care, pain management, and follow-up appointments.  ICD-10 code L02.411 (Right buttock abscess) is appropriate for this diagnosis.  CPT codes for incision and drainage will vary depending on the complexity of the procedure (e.g., 10060, 10061).  Follow-up care includes wound check and dressing changes as needed.  Potential complications include sepsis, fistula formation, and recurrent abscess.  Patient advised to monitor for signs of worsening infection such as increasing pain, fever, or spreading redness.