ICD-10 Guide

Abscess Of Buttock

ICD-10 Coding for Abscess of Buttock(L02.31)

PRIMARY SPECIALTYGeneral Surgery

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Abscess Of Buttock?

An abscess of the buttock is a localized collection of pus that occurs in the soft tissues of the buttock region, often resulting from bacterial infection. Key clinical points include: 1) Commonly caused by Staphylococcus aureus, particularly in cases of skin trauma or folliculitis. 2) Patients may present with pain, swelling, redness, and warmth in the affected area. 3) Systemic symptoms such as fever may also be present in more severe cases. Typical use cases for the ICD-10 code L02.31 include outpatient visits for drainage procedures, inpatient admissions for severe infections, and follow-up visits post-surgery. The pathophysiology involves the accumulation of pus due to the body's immune response to infection, leading to tissue necrosis and inflammation. Clinically, abscesses may present as tender, fluctuant masses that can be diagnosed through physical examination and imaging when necessary.

Key Clinical Considerations:

Diagnosis is confirmed through clinical examination showing a fluctuant mass in the buttock region.
Signs include localized pain, swelling, erythema, and possible drainage of purulent material.
Resolution is indicated by the absence of pain, reduction in swelling, and healing of the skin.
Imaging studies such as ultrasound may reveal the extent of the abscess and guide treatment.

Clinical Information

Clinical Criteria & Documentation Requirements

Documentation must include the location, size, and characteristics of the abscess, as well as any systemic symptoms.
Compliant documentation: 'Patient presents with a 3 cm fluctuant abscess on the left buttock, with associated fever.' Non-compliant: 'Patient has an abscess.'
Template phrases include: 'Abscess located at [specific site] with [symptoms].'
Medical necessity must be established through documentation of symptoms, treatment rationale, and follow-up plans.

Coding Guidelines

Usage Guidelines & Examples

Use L02.31 when a patient presents with a localized abscess in the buttock without systemic involvement. Example: A patient with a painful, swollen area on the buttock requiring incision and drainage.
Do NOT use this code for non-infected cysts or other lesions that do not involve pus formation.
Correct usage: L02.31 for a draining abscess; incorrect: L02.9 for unspecified skin abscess.
Common errors include misclassifying abscesses as cellulitis (L03.21) or failing to document the site of the abscess.

Code Exclusions

Important Exclusions

Excluded conditions include pilonidal cysts (L05.0) and other non-infectious lesions.
Alternative codes for exclusions may include L02.9 for unspecified abscesses.
Common exclusion errors involve misdiagnosing a pilonidal cyst as an abscess.
Certain conditions are excluded due to differing treatment protocols and clinical implications.

Specialty Focus

Primary Specialty

General Surgery

Specialty Applications

This diagnosis applies to patients with localized infections in the buttock region.
Appropriate in clinical scenarios involving acute pain and swelling in the buttock.
Applicable in both outpatient and inpatient settings, especially in surgical contexts.
General surgery and dermatology specialties frequently utilize this code for abscess management.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Template 1

Template: 'Abscess diagnosed based on clinical findings of [specific symptoms].'

Template 2

Template: 'Patient presents with [symptoms] consistent with abscess of the buttock.'

Template 3

Template: 'Diagnostic criteria met: [specific findings such as fluctuation].'

Template 4

Template: 'Treatment plan includes incision and drainage for abscess of the buttock.'

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

What documentation is required for this code?

Detailed documentation of the abscess's characteristics, treatment plan, and follow-up care.

When should this code be used vs similar codes?

Use L02.31 specifically for abscesses; use L03.21 for cellulitis or L02.9 for unspecified abscess.

What are common billing issues with this code?

Reimbursement may be denied if documentation does not support the diagnosis or if the procedure is not medically necessary.

What procedures are commonly associated?

CPT codes for incision and drainage (10060, 10061) are often linked with this diagnosis.

What is Abscess Of Buttock?

Key Clinical Considerations:

Diagnosis is confirmed through clinical examination showing a fluctuant mass in the buttock region.
Signs include localized pain, swelling, erythema, and possible drainage of purulent material.
Resolution is indicated by the absence of pain, reduction in swelling, and healing of the skin.
Imaging studies such as ultrasound may reveal the extent of the abscess and guide treatment.

Abscess Of Buttock

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Template 1

Template 2

Template 3

Template 4

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What documentation is required for this code?

When should this code be used vs similar codes?

What are common billing issues with this code?

What procedures are commonly associated?

Abscess Of Buttock

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Template 1

Template 2

Template 3

Template 4

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What documentation is required for this code?

When should this code be used vs similar codes?

What are common billing issues with this code?

What procedures are commonly associated?