PCS help: Pelvis or peritoneal cavity?
Have a MALE pt that came in with "intra-abdominal abscess" with history of recent ruptured appendicitis and appendectomy. How would you code this surgery from op report?
"Preoperative dx: Intraabdominal abscess; possible retained fecalith
Postop dx: same but no fecalith identified
Procedure: Laparoscopic drainage of intraabdominal abscess.
I began dissection in the right lower quadrant and pelvis and many bowel loops were separated from each other. To do this I had to add an additional 5 mm port in the right midabdomen, also under direct vision, because the right lower quadrant port was limiting. Once I had access to the pelvis it was apparent that the bladder was adhered to the rectosigmoid. As I separated these structures I was able to find and drain the abscess and cultures were sent. A 15 Fr JP drain was placed through the left lower quadrant port site and the fenestrated end was placed in the abscess cavity.
Findings: No obvious fecalith seen; Pelvic abscess identified and drain"
Prog notes: Surgery POD #1: S/P exploratory laparoscopy and drainage of pelvic abscess
Attending: male with hx of perforated appendix s/p appendectomy, treated inpatient with aztreonam and flagyl & discharged without further abx, followed up on 4/22 and now returning with fever from 4/25-present found to have 5cm pelvic abscess in the pouch of douglas s/p laparoscopic drainage of intra-abdominal abscess POD #1.
Would you use: 0W9G4ZZ Drainage of peritoneal cavity, perc endo approach (DRG 373-371) ? Or 0W9J4ZZ Drainage of pelvic cavity, perc endo approach (DRG 358-356)?
From what I can find about the "pouch of Douglas" (rectovesical pouch in males), it is a double folding of peritoneum located between the rectum and the bladder and is lowest part of peritoneal cavity. Since surgeon is documenting "pelvic abscess", I am leaning towards 0W9J4ZZ.
Any advice??? Do I need to query to clarify whether it is pelvic or peritoneal cavity? (Big difference in DRG from what I can find.)
Thanks in advance!
Claudine
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