Health Information Management

Q&A: Coding for aspiration of peritonsillar abscess

JustCoding News: Inpatient, August 15, 2012

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Q: A patient has been diagnosed with peritonsillar cellulitis and oropharyngeal cellulitis. The physician documents that he performed a “needle aspiration of the left peritonsillar abscess.” In the body of the operative report, the physician states, “An 18-gauge needle was inserted and 1 cc of pus was aspirated. This was sent for aerobic, anaerobic, C&S [culture & sensitivity], and gram stain. I then put the 18-gauge needle in again and multiple passes were obtained without any aspirate.”

Because ICD-9-CM does not include a code for “aspiration of peritonsillar abscess” some coders wanted to use ICD-9-CM procedure code 28.0 (incision and drainage of tonsil and peritonsillar structures) while others want to report code 28.99 (other operations on tonsils and adenoids). Which code is correct?
A: Based on what you wrote here, code 28.0 (drainage of peritonsillar abscess) is appropriate. The incision is the insertion of the 18-gauge needle and the drainage can be performed by aspiration or other methodology.
In addition, you will need a diagnosis code to report the existence of the abscess that was drained (aspirated). Cellulitis is an inflammation whereas an abscess is a collection of purulent or other fluid. Take a look at ICD-9-CM code 475 (peritonsillar abscess).
Editor’s Note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, Fla., answered this question.
This answer was provided based on limited information that was submitted to Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
Need expert coding advice? Submit your question to Senior Managing Editor Andrea Kraynak, CPC, at, and we’ll do our best to get an answer for you.

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