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CPT 49060: Incision and Drainage of Retroperitoneal Abscess

CPT code 49060 identifies an open surgical procedure for incision and drainage of a retroperitoneal abscess. This code denotes definitive surgical management of an abscess located behind the peritoneal lining and is relevant to hospitals, surgical departments, and payers managing inpatient and operative surgical care. Nationally, surgical drainage of deep abdominal infections carries implications for utilization, inpatient resource use, and postoperative care pathways.

Key payers referenced include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on clinical indications for open retroperitoneal abscess drainage, typical settings of care (operating room or surgical suite), and the role of this procedure in acute surgical management. The publication also covers billing and coding considerations, common modifier usage where applicable, and how this procedure fits into broader surgical service lines and quality reporting frameworks. Practical benchmarks and policy updates relevant to surgical services and inpatient procedure reimbursement are summarized to inform revenue cycle, coding compliance, and clinical operations teams.

Data not available in the input for specific payer rates, associated taxonomies, and ICD-10 diagnosis pairings.

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Billing Code Overview

CPT code 49060 describes an open surgical procedure in which the clinician makes an incision in the abdomen to drain an abscess located in the retroperitoneal space (the area behind and outside the posterior peritoneal lining). This procedure is a surgical drainage of a retroperitoneal abscess and involves direct access to the retroperitoneum through an abdominal incision.

Service type: Surgical — Open drainage procedure

Typical site of service: Operating room or surgical suite

Find policies, billing codes, payers, states, and providers

CPT 49060: Incision and Drainage of Retroperitoneal Abscess

Data not available in the input for specific payer rates, associated taxonomies, and ICD-10 diagnosis pairings.

Customize your policy alerts

Sign up for cpt 49060 policy alerts

Get alerted when payer policies referencing 49060 are released or updated.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Billing Code Overview

Service type: Surgical — Open drainage procedure

Typical site of service: Operating room or surgical suite

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult presenting to the emergency department or surgical service with fever, localized back or flank pain, leukocytosis, and imaging (CT scan) demonstrating a retroperitoneal abscess. The patient may have risk factors such as recent intra-abdominal infection, perforated viscus, pancreatitis, urinary tract infection, diabetes mellitus, or recent abdominal surgery. Initial workflow includes triage, focused history and exam, laboratory evaluation (CBC, BMP), blood cultures if febrile, and CT abdomen/pelvis with contrast to localize the collection. Interventional radiology may attempt percutaneous drainage; however, when percutaneous approaches are infeasible due to location, multiloculation, or overlying bowel, a general or acute care surgeon performs an open drainage via an abdominal incision to access the retroperitoneal space, evacuate purulent material, culture the fluid, place drains as needed, and irrigate the cavity. Post-procedure management includes intravenous antibiotics tailored to culture results, wound and drain care, monitoring for sepsis, and imaging follow-up as clinically indicated. Typical sites of service are the hospital operating room, emergency department procedure area, or inpatient surgical unit. The service type is an open surgical incision and drainage of a retroperitoneal abscess corresponding to acute surgical intervention and inpatient care when indicated.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the work required is substantially greater than usual for `49060` (e.g., extensive adhesiolysis, difficult anatomy, markedly obese patient).
`23`	Unusual anesthesia	Use when general anesthesia cannot be used and anesthesia provided is unusual for the procedure.
`26`	Professional component	Use when reporting only the professional component of a service if applicable to imaging or interpretation components related to the case.
`52`	Reduced services	Use when a surgically planned portion of the procedure is not completed or only partially performed.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to extenuating circumstances before completion.
`54`	Surgical care only	Use when only the surgeon’s operative portion is billed and another provider bills pre- and post-operative care.
`55`	Postoperative management only	Use when billing only the postoperative care period separate from another surgeon’s operative billing.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct portions of `49060`.
`80`	Assistant surgeon	Use when an assistant surgeon is present and performs a defined portion of the operation.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist	Use when an advanced practice clinician performs services within payer policy allowances for `49060` under supervision or state scope.
`51`	Multiple procedures	Use when `49060` is reported with additional procedures on the same operative day; append `51` per payer rules if required.
`58`	Staged or related procedure or service by same physician during the postoperative period	Use when the drainage is a planned staged procedure following an initial operation.
`76`	Repeat procedure by same physician	Use when the same surgeon performs a repeat drainage procedure during the same encounter.
`62`	Co-surgeons (duplicate entry avoided)	(Note: `62` already listed)

Taxonomy Code	Specialty	Notes
208000000X	General Surgery	Most commonly performs open drainage of retroperitoneal abscesses.
208600000X	Colon and Rectal Surgery	Involved when colorectal sources or pelvic/retroperitoneal extension are present.
2084P0800X	Acute Care Surgery	Trauma/acute care surgeons manage emergent intra-abdominal sepsis and retroperitoneal collections.
363L00000X	Interventional Radiology	Performs percutaneous drainage attempts; consulted for image-guided approaches and drain placement.
207R00000X	Urology	Involved when urinary tract source or retroperitoneal extension from urologic infection is suspected.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K65.0`	Acute peritonitis	May coexist with or complicate intra-abdominal infections leading to retroperitoneal abscess requiring drainage.
`K65.9`	Peritonitis, unspecified	Represents intra-abdominal infectious processes that may be associated with retroperitoneal collections.
`N13.6`	Pyonephrosis	Infections of the renal collecting system can extend to the retroperitoneum necessitating open drainage.
`N39.0`	Urinary tract infection, site not specified	Urologic sources can seed retroperitoneal infections in susceptible patients.
`K57.20`	Diverticulitis of large intestine with perforation and abscess without bleeding	Colonic perforation with abscess formation can extend into the retroperitoneal space.
`K86.0`	Alcohol-induced chronic pancreatitis	Pancreatic infections or pseudocyst infections can track into retroperitoneum and form abscesses.
`A41.9`	Sepsis, unspecified organism	Systemic infection resulting from retroperitoneal abscess; common complication prompting urgent drainage.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`10160`	Incision and drainage of abscess, simple or single; skin, subcutaneous tissue, or mucous membrane	May be performed for superficial abscesses prior to or instead of deeper `49060` drainage; not appropriate for retroperitoneal collections.
`49405`	Drainage of intra-abdominal abscess, percutaneous; with imaging guidance	Often attempted first as a less invasive alternative to open `49060` when an image-guided percutaneous approach is feasible.
`49002`	Drainage of perirenal abscess, open	Related open drainage codes for perirenal collections; selected when abscess location is perirenal rather than retroperitoneal posterior wall.
`11042`	Debridement; subcutaneous tissue (includes epidermis and dermis when performed)	May be billed when extensive wound debridement of the overlying soft tissues is performed in conjunction with `49060`.
`49560`	Drainage of abdominal wall abscess; complicated	Performed when an abdominal wall component or infected incision/hematoma requires separate drainage along with retroperitoneal access.
`32900`	Thoracotomy, with exploration and drainage of pleural space (example unrelated anatomic area)	Data not available in the input.

CPT 49000: Intra-Abdominal Exploration with Biopsy

CPT-49002-EXPLORATORY-REOPENING-OF-ABDOMINAL-INCISION

CPT 49002: Reopening of Abdominal Incision for Exploration

CPT-49010-RETROPERITONEAL-EXPLORATION-WITH-BIOPSY

CPT 49010: Retroperitoneal Exploration with Biopsy

CPT-49013-PELVIC-PREPERITONEAL-PACKING-FOR-HEMORRHAGE-CONTROL

CPT 49013: Preperitoneal Pelvic Packing for Hemorrhage Control

CPT-49014-PELVIC-CAVITY-REOPENING-AND-REMOVAL-OF-PACKING

CPT 49014: Reopening Pelvic Cavity and Removal of Preperitoneal Packing

CPT-49020-OPEN-INCISION-DRAINAGE-INTRA-ABDOMINAL-ABSCESS

CPT 49020: Open Incision and Drainage of Intra‑abdominal Abscess

CPT-49040-SUBDIAPHRAGMATIC-ABSCESS-INCISION-AND-DRAINAGE

CPT 49040: Incision and Drainage of Subdiaphragmatic Abscess

CPT-49062-EXTRAPERITONEAL-LYMPHATIC-FLUID-DRAINAGE

CPT 49062: Extraperitoneal Lymphatic Fluid Drainage

CPT-49082-ABDOMINAL-PARACENTESIS-WITHOUT-IMAGING

CPT 49082: Abdominal Paracentesis Without Imaging

CPT-49083-IMAGE-GUIDED-ABDOMINAL-PARACENTESIS

CPT 49083: Image-Guided Abdominal Paracentesis

Showing 1–10 of 11

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the work required is substantially greater than usual for `49060` (e.g., extensive adhesiolysis, difficult anatomy, markedly obese patient).
`23`	Unusual anesthesia	Use when general anesthesia cannot be used and anesthesia provided is unusual for the procedure.
`26`	Professional component	Use when reporting only the professional component of a service if applicable to imaging or interpretation components related to the case.
`52`	Reduced services	Use when a surgically planned portion of the procedure is not completed or only partially performed.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to extenuating circumstances before completion.
`54`	Surgical care only	Use when only the surgeon’s operative portion is billed and another provider bills pre- and post-operative care.
`55`	Postoperative management only	Use when billing only the postoperative care period separate from another surgeon’s operative billing.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct portions of `49060`.
`80`	Assistant surgeon	Use when an assistant surgeon is present and performs a defined portion of the operation.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist	Use when an advanced practice clinician performs services within payer policy allowances for `49060` under supervision or state scope.
`51`	Multiple procedures	Use when `49060` is reported with additional procedures on the same operative day; append `51` per payer rules if required.
`58`	Staged or related procedure or service by same physician during the postoperative period	Use when the drainage is a planned staged procedure following an initial operation.
`76`	Repeat procedure by same physician	Use when the same surgeon performs a repeat drainage procedure during the same encounter.
`62`	Co-surgeons (duplicate entry avoided)	(Note: `62` already listed)

Taxonomy Code	Specialty	Notes
208000000X	General Surgery	Most commonly performs open drainage of retroperitoneal abscesses.
208600000X	Colon and Rectal Surgery	Involved when colorectal sources or pelvic/retroperitoneal extension are present.
2084P0800X	Acute Care Surgery	Trauma/acute care surgeons manage emergent intra-abdominal sepsis and retroperitoneal collections.
363L00000X	Interventional Radiology	Performs percutaneous drainage attempts; consulted for image-guided approaches and drain placement.
207R00000X	Urology	Involved when urinary tract source or retroperitoneal extension from urologic infection is suspected.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K65.0`	Acute peritonitis	May coexist with or complicate intra-abdominal infections leading to retroperitoneal abscess requiring drainage.
`K65.9`	Peritonitis, unspecified	Represents intra-abdominal infectious processes that may be associated with retroperitoneal collections.
`N13.6`	Pyonephrosis	Infections of the renal collecting system can extend to the retroperitoneum necessitating open drainage.
`N39.0`	Urinary tract infection, site not specified	Urologic sources can seed retroperitoneal infections in susceptible patients.
`K57.20`	Diverticulitis of large intestine with perforation and abscess without bleeding	Colonic perforation with abscess formation can extend into the retroperitoneal space.
`K86.0`	Alcohol-induced chronic pancreatitis	Pancreatic infections or pseudocyst infections can track into retroperitoneum and form abscesses.
`A41.9`	Sepsis, unspecified organism	Systemic infection resulting from retroperitoneal abscess; common complication prompting urgent drainage.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`10160`	Incision and drainage of abscess, simple or single; skin, subcutaneous tissue, or mucous membrane	May be performed for superficial abscesses prior to or instead of deeper `49060` drainage; not appropriate for retroperitoneal collections.
`49405`	Drainage of intra-abdominal abscess, percutaneous; with imaging guidance	Often attempted first as a less invasive alternative to open `49060` when an image-guided percutaneous approach is feasible.
`49002`	Drainage of perirenal abscess, open	Related open drainage codes for perirenal collections; selected when abscess location is perirenal rather than retroperitoneal posterior wall.
`11042`	Debridement; subcutaneous tissue (includes epidermis and dermis when performed)	May be billed when extensive wound debridement of the overlying soft tissues is performed in conjunction with `49060`.
`49560`	Drainage of abdominal wall abscess; complicated	Performed when an abdominal wall component or infected incision/hematoma requires separate drainage along with retroperitoneal access.
`32900`	Thoracotomy, with exploration and drainage of pleural space (example unrelated anatomic area)	Data not available in the input.

CPT 49000: Intra-Abdominal Exploration with Biopsy

CPT-49002-EXPLORATORY-REOPENING-OF-ABDOMINAL-INCISION

CPT 49002: Reopening of Abdominal Incision for Exploration

CPT-49010-RETROPERITONEAL-EXPLORATION-WITH-BIOPSY

CPT 49010: Retroperitoneal Exploration with Biopsy

CPT-49013-PELVIC-PREPERITONEAL-PACKING-FOR-HEMORRHAGE-CONTROL

CPT 49013: Preperitoneal Pelvic Packing for Hemorrhage Control

CPT-49014-PELVIC-CAVITY-REOPENING-AND-REMOVAL-OF-PACKING

CPT 49014: Reopening Pelvic Cavity and Removal of Preperitoneal Packing

CPT-49020-OPEN-INCISION-DRAINAGE-INTRA-ABDOMINAL-ABSCESS

CPT 49020: Open Incision and Drainage of Intra‑abdominal Abscess

CPT-49040-SUBDIAPHRAGMATIC-ABSCESS-INCISION-AND-DRAINAGE

CPT 49040: Incision and Drainage of Subdiaphragmatic Abscess

CPT-49062-EXTRAPERITONEAL-LYMPHATIC-FLUID-DRAINAGE

CPT 49062: Extraperitoneal Lymphatic Fluid Drainage

CPT-49082-ABDOMINAL-PARACENTESIS-WITHOUT-IMAGING

CPT 49082: Abdominal Paracentesis Without Imaging

CPT-49083-IMAGE-GUIDED-ABDOMINAL-PARACENTESIS

CPT 49083: Image-Guided Abdominal Paracentesis

Showing 1–10 of 11

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

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CPT 49060: Incision and Drainage of Retroperitoneal Abscess

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Billing Code Overview

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CPT 49060: Incision and Drainage of Retroperitoneal Abscess

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

CPT 49060: Incision and Drainage of Retroperitoneal Abscess

Sign up for cpt 49060 policy alerts

Billing Code Overview

CPT 49060: Incision and Drainage of Retroperitoneal Abscess

Sign up for cpt 49060 policy alerts

Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What does CPT 49060 represent and where is this service typically performed?

When is open drainage (49060) performed instead of percutaneous drainage?

Which common modifiers are associated with reporting CPT 49060?

Which specialties commonly perform or are involved in CPT 49060 cases?

What diagnoses and related CPT codes are commonly associated with CPT 49060 cases?

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What does CPT 49060 represent and where is this service typically performed?

When is open drainage (49060) performed instead of percutaneous drainage?

Which common modifiers are associated with reporting CPT 49060?

Which specialties commonly perform or are involved in CPT 49060 cases?

What diagnoses and related CPT codes are commonly associated with CPT 49060 cases?

References