AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 3; Ask the Editor

Incision and Drainage of Retropharyngeal Space Abscess

The patient presented for incision and drainage of an abscess in the retropharyngeal space. At surgery, the skin was incised two fingerbreadths below the mandible anterior to the left sternocleidomastoid (SCM). The subcutaneous fat was dissected, platysma was ligated and the anterior border of the left SCM was retracted with continued dissection posteriorly and superiorly behind the muscle belly. The abscess cavity was encountered in the retropharyngeal space which was finger dissected across the midline up and down the cervical vertebra and along the medial cortex of the mandible. Pus was aspirated, the cavity was flushed and a Penrose drain was sutured into place. ICD-10-PCS does not provide a distinct body part value for retropharyngeal space. How is drainage of a retropharyngeal abscess coded in ICD-10-PCS? ...

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