Oncology & Hematology Coding Alert

Question: In a patient suspected to have ovarian tumor, our oncology obtained a sample of the fluid from the ovarian cyst under ultrasound guidance. How should we report this procedure?

Utah Subscriber

Answer: You will need to confirm the method used to collect the cystic sample (drainage or fine needle aspiration).

If the method to obtain the sample required 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)

Report the radiologic component for guidance with:

• 76942 (Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) imaging supervision and interpretation). Usually ultrasound codes do not require a modifier. When using ultrasound guidance during a procedure, the provider must document the indication for doing it as well as what was visualized.

If the method to obtain the sample was a fine needle aspiration (FNA), the following codes would be more appropriate:

• 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)
• +10006 (Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure))

The FNA codes were heavily updated in 2019 with code 10022 deleted and codes 10004-10012 added. Code 10022 historically represented FNA with imaging guidance and a separate code was reported for the appropriate type of guidance. Now, the FNA with imaging guidance codes are differentiated by type of guidance utilized with options for ultrasound, fluoroscopic, CT and MR. The codes are also reported by first lesion with an add on code for each additional lesion.

Radiologic supervision and interpretation codes require documentation of imaging type performed, visualization of needle placement, and interpretation of the images.

If the procedure was performed in another manner, these codes may not be appropriate. Consult with the physician who performed the procedure. Verify the method and specifics to report the correct CPT^® codes for the services rendered.