Perirectal Abscess Incision and Drainage
4604046050wRVU: 1.21 — Perianal abscess I&D, superficial46270wRVU: 4.8 — Fistulotomy, intersphincteric fistula (if concurrent)46020wRVU: 1.81 — Seton placement (if high fistula identified)
[Perianal / ischiorectal / intersphincteric / supralevator] abscess, [right / left]
Same
Incision and drainage of [perianal / ischiorectal / intersphincteric] abscess, [right / left] [with fistulotomy / with seton placement / drainage only]
[Attending name], MD
[Resident name]
[General / spinal / MAC / local with sedation]
Patient presents with [painful / fluctuant / indurated] [right / left] [perianal / ischiorectal] abscess with [X] days of symptoms. [Fever / leukocytosis present.] [Diabetes / immunosuppression / Crohn disease present.] Examination under anesthesia and I&D planned. Risks including fistula formation (50% of perirectal abscesses), recurrence, and sphincter injury discussed. Consent obtained.
[Perianal / ischiorectal / intersphincteric] abscess, [right / left], approximately [X] cm. [Purulent / malodorous] fluid drained. [Internal opening identified at [X] o'clock at the dentate line / no internal opening identified.] Sphincter [intact / not violated]. [Horseshoe extension posteriorly noted, counter-incision placed.]
The patient was positioned in the [prone jackknife / lithotomy] position. The perianal area was prepped and draped in sterile fashion. Examination under anesthesia confirmed [right ischiorectal / perianal] fluctuance.
A [cruciate / elliptical / radial] incision was made over the point of maximal fluctuance as close to the anal verge as feasible to minimize fistula tract length. The abscess was entered and [purulent fluid evacuated, [X] mL of [purulent / bloody-purulent] fluid drained]. The cavity was digitally explored and broken up to ensure complete drainage. The wound was irrigated with [warm saline].
Anoscopy was performed. [An internal opening was identified at the [X] o'clock position at the dentate line, consistent with a cryptoglandular fistula.] [No internal opening was identified.]
[FISTULOTOMY:] A probe was passed from the external wound through the internal opening. The overlying tissue (including a [superficial / distal intersphincteric / subcutaneous] portion of the [internal / external] sphincter) was divided with electrocautery over the probe. The fistula tract was marsupialized and curretted.
[SETON:] Given the [high / transsphincteric] nature of the fistula, a [vessel loop / 0-silk / silastic] seton was passed through the tract and secured loosely [/ with gentle tension] for staged drainage.
The wound was packed with [iodoform gauze]. Sitz baths instructed postoperatively. Patient tolerated the procedure well.
None
[Abscess wall / purulent material sent for culture / None]
Minimal
Wound packed open
Patient to PACU. Discharged home with wound care, sitz bath instructions, and follow-up in 2-3 weeks for fistula evaluation.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Perianal / ischiorectal / intersphincteric] abscess, [right / left]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Incision and drainage, [perianal / ischiorectal] abscess, [right / left] [with fistulotomy / with seton / drainage only]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / spinal / MAC]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [right / left] [perianal / ischiorectal] abscess, *** days. [Fever / leukocytosis.] [Crohn / diabetes / immunosuppression.] Risks including fistula formation and recurrence discussed. Informed consent obtained.
FINDINGS: [Ischiorectal / perianal] abscess, *** cm. [Purulent] fluid drained. [Internal opening at *** o'clock at dentate line / no internal opening.] Sphincter intact. [Horseshoe extension, counter-incision placed.]
DESCRIPTION OF PROCEDURE:
Patient [prone jackknife / lithotomy]. Perianal area prepped. EUA confirmed [right ischiorectal / perianal] fluctuance. [Cruciate / elliptical / radial] incision over point of maximal fluctuance close to anal verge. Abscess entered; *** mL purulent fluid drained; cavity digitally broken up; irrigated with saline. Anoscopy performed. [Internal opening at *** o'clock / no internal opening identified.] [FISTULOTOMY: probe passed; overlying tissue divided with electrocautery; tract marsupialized.] [SETON: vessel loop / silk seton placed through tract, secured loosely.] Wound packed with iodoform gauze. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Abscess contents for culture / None]
COMPLICATIONS: None
DRAINS: Wound packed open
DISPOSITION: Patient to PACU. Discharged home with sitz baths. Follow-up 2-3 weeks for fistula evaluation.
Signed: .ME, .MYDEGREE
.TODAYVariants
Horseshoe abscess
Posterior communication between bilateral ischiorectal spaces. Drain primary posterior space via posterior midline incision at Hilton's white line; counter-drainage incisions bilaterally. Document extent, counter-incisions placed, and deep postanal space drainage.
Supralevator abscess
Above the levator ani. Drainage approach depends on origin. If from upward extension of ischiorectal abscess, drain through ischiorectal fossa (not transrectally). If from pelvic pathology, drain transrectally or via CT-guided drain. Never drain both spaces, as this creates an iatrogenic supralevator fistula.
Crohn perianal abscess
Conservative drainage with seton preferred. Avoid aggressive fistulotomy, as wound healing in Crohn is poor. Document Crohn status, current biologics, and plan for gastroenterology co-management of fistula disease.
Charting Tips
- Document abscess location by space (perianal, ischiorectal, intersphincteric, supralevator), as this drives CPT and management
- Note presence or absence of internal opening and position (clock-face, relation to dentate line)
- Document sphincter integrity (assess how much sphincter, if any, is at risk)
- State whether fistulotomy or seton was placed and rationale
- Fistula evaluation at 6-8 weeks postoperatively is standard. Document plan for follow-up.
- Horseshoe anatomy requires explicit description of all spaces drained
Billing Tips
- Bill 46040 for incision and drainage of ischiorectal and/or perirectal abscess (5.78 wRVU, 0-day global). Bill 46050 for superficial perianal abscess I&D (2.16 wRVU). Use 46040 for deep-space abscesses (ischiorectal, intersphincteric, supralevator) and 46050 for simple superficial perianal abscesses that do not require examination under anesthesia.
- Fistulotomy at the same session: when an identifiable fistula tract is present and laid open concurrently, bill 46270 (fistulotomy, simple, 5.21 wRVU) in addition to 46040. Do not bill fistulotomy unless the tract is definitively identified and divided. Presumed fistula at the time of abscess I&D is documented but not billed separately.
- Seton placement for complex or high fistula: bill 46020 (placement of seton, 3.55 wRVU) when a seton is placed at the time of abscess drainage. Document seton type (cutting vs. draining), material, and position.
- 0-day global period: no postoperative surgical fees are bundled. Follow-up wound care, sitz baths, and fistula evaluation visits are separately billable with E/M codes. Recurrent abscess drainage is a new procedure each time.
- Horseshoe abscess (bilateral ischiorectal involvement with posterior communication) is more complex than a simple abscess. Document the anatomy, counter-incisions, and extent of drainage. Supports modifier -22 for increased complexity if substantially more difficult than standard.