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
Cutaneous abscess of buttock
Abscess located in the skin of the buttock region.
Cutaneous abscess, unspecified
Abscess in the skin, without a more specific location given.
Enthesopathy of gluteal region
Disorder where tendons/ligaments attach to the bone in the buttock, possibly related to deep abscess.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the abscess related to a pilonidal cyst?
When to use each related code
| Description |
|---|
| Right buttock abscess |
| Pelvic abscess |
| Pilonidal cyst/abscess |
Coding right buttock abscess without specifying laterality can lead to claim rejection. Use L89.011 for right side.
Lack of specific anatomical location within buttock (e.g., ischiorectal) may impact reimbursement. Ensure proper documentation.
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.
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.