General Surgery Coding Alert

Question: Our surgeon obtained a sample of fluid from an ovarian cyst under ultrasound guidance for a patient to rule out ovarian cancer. How should we code the procedure?

Nevada Subscriber

Answer: You don’t provide enough information to accurately assign a surgical code. You’ll have to confirm the method the surgeon used to collect the specimen before you can choose the correct code.

The main question is whether the surgeon was draining the cyst as treatment, or taking a sample, such as a fine needle aspiration (FNA), for diagnostic purposes. The answer will direct you to different codes.

If the surgeon performed incision and drainage, 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)

The surgeon did document ultrasound guidance, so you might additionally report 76942 (Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) imaging supervision and interpretation).

FNA: On the other hand, if the surgeon extracts an FNA specimen for diagnosis under ultrasound guidance, you should report 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion). If the surgeon aspirates a second lesion or cyst, you should additionally report +10006 (… each additional lesion (List separately in addition to code for primary procedure)).

Bottom line: If the op report doesn’t provide any more information than you’ve mentioned in your question, you’ll need to contact the surgeon for clarification before coding the procedure.