General Surgery Coding Alert

Question: The surgeon extracted a fluid sample from an ovarian cyst using ultrasound guidance. The op note states, “suspicious for ovarian tumor.” Please advise how to correctly code this case.

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Answer: To choose the appropriate procedure code, you’ll need to confirm the method your surgeon used to collect the cystic sample (cyst drainage or fine needle aspiration).

If the surgeon used incision and drainage (I&D), you have the following two codes to choose from, depending on the approach:

• 58800 (Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach)
• 58805 (… abdominal approach).

Report the radiologic component for guidance with 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation). When using ultrasound guidance during a procedure, the surgeon must document the indication for the ultrasound, as well as what was visualized using the procedure.

If the method to obtain the sample was a fine needle aspiration (FNA), it would be more appropriate to report 10022 (Fine needle aspiration; with imaging guidance). In that case, you would report the radiologic component using 76942 (Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation).

Tip: Whether FNA or I&D, the radiologic supervision and interpretation codes require documentation of imaging type performed, visualization of needle placement, and interpretation of the images.