Oncology & Hematology Coding Alert

Question: Our physician obtained a sample of the fluid from the ovarian cyst under ultrasound guidance. He suspects the patient has an ovarian tumor. How should we report this procedure?

Florida 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 (Drainage of ovarian cyst[s], unilateral or bilateral [separate procedure]; 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:

• 10021 (Fine needle aspiration; without imaging guidance)
• 10022 (Fine needle aspiration; with imaging guidance)

And, you would report the radiologic component for guidance of the FNA for code 10022 with:

• 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation)

In both cases, the 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.