Radiology Coding Alert

Know what terminology to look out for in the dictation report.

For beginning radiology coders tasked with working on minor interventional services such as image-guided percutaneous aspiration and drainage procedures, there are numerous obstacles within the dictation report that can get in between the coder and the correct CPT^® code.

That’s because, on the surface, these procedure sets can look quite familiar next to one another. You’ve got to know exactly what to look out for in order to set apart a percutaneous aspiration from a drainage procedure. As you’ll see, much of what you’re looking for is the physician’s use of the catheter.

Use these two clinical examples to get you well on your way easily discerning between percutaneous aspirations and drainages.

Begin By Defining Key Terms

Before diving into some examples, you need to have a firm understanding of the underlying differences between image-guided percutaneous aspiration and drainage procedures. As you’ll see, the often sole differentiating feature between a percutaneous aspiration and a drainage involves the use of the catheter. More specifically, if the catheter is immediately removed following the procedure, then, by definition, it’s an aspiration. If the catheter remains in for the site to drain following the procedure, you are coding a drainage.

Once that point is driven home, there’s another factor to consider — imaging guidance. Both procedures involve imaging guidance, but that doesn’t mean that each code includes imaging guidance. When coding drainage procedures, you don’t have to worry about separately reporting imaging guidance — it’s included in the code. Consider a few of the more common drainage codes:

• 10030 — Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous
• 32557 — Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance
• 49405 — Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous
• 49406 — Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperi­toneal, percutaneous.

Coder’s note: Image guidance for these procedures can include fluoroscopy, ultrasound (US), or computed tomography (CT).

On the other hand, you’ll have to consider the code description of the percutaneous aspiration procedure you are coding in order to determine whether imaging guidance can be coded separately. As you will see, outside of thoracentesis and paracentesis procedures, imaging guidance must be reported separately. Consider these more common percutaneous aspiration codes:

• 10160 — Puncture aspiration of abscess, hematoma, bulla, or cyst
• 19000 — Puncture aspiration of cyst of breast
• 32555 — Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance
• 49083 — Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance
• 50390 — Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous.

Practice With These Clinical Examples

Now that you’ve got a clearer picture of what’s required in order to report each respective service, have a look at the following two examples to drive the point home:

Exam: Ultrasound-guided aspiration of a recurrent left breast seroma

Body: Initial sonographic evaluation confirmed a collection of fluid in the right breast measuring 5 x 5.2 x 2.1 cm, consistent with the patient`s recurrent right breast seroma. The right breast was prepped in usual sterile fashion. Local anesthesia was obtained with 1% lidocaine. A Yueh Centesis catheter needle was advanced directly into the seroma. The catheter was then removed. A total of 46 ml of fluid was aspirated and sent to pathology.

The exam references an image-guided aspiration, so you should be looking in the body of the report documentation to support an aspiration. Since the catheter was removed following the aspiration, you now know that you should report an aspiration code for a seroma of the breast. Additionally, you know that you will also need to report a separate imaging guidance code.

You might initially consider code 19000 since it’s the only aspiration procedure directly involving the breast. However, you should only report 19000 for aspirations of cysts of the breast, not seromas. Seromas, along with other fluid collections in the breast (abscess, hematoma, etc.) should be reported with code 10160.

Next, you’ll want to report the appropriate US guidance code. Specifically, you will opt for the US guidance code for needle placement. Report code 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) alongside 10160.

Next, have a look at an example involving an abscess drainage procedure:

Exam: CT-guided percutaneous needle peritoneal abscess drainage

Body: Using a 17-gauge needle, the fluid collection seen along the anterior wall of the urinary bladder contiguous with sigmoid colon was punctured. An aspirate of approximately 16 ml of purulent drainage was obtained. The catheter was sutured securely in place and connected to a Jackson-Pratt bulb for continued drainage.

As you can see, you will not be reporting an aspiration procedure since the catheter was left in place following the operation. Since this is a drainage of an abscess of the peritoneal and retroperitoneal space, you will report code 49406. This code includes the CT imaging guidance performed during the procedure.

If the provider had removed the catheter following the procedure, you would instead report this procedure as an aspiration. More specifically, you would report abdominal paracentesis code 49083. “Paracentesis, by definition, is an aspiration of fluid from the abdominal cavity,” explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “For abdominal fluid removal procedures involving the subsequent removal of the catheter needle, you would opt for paracentesis code 49083,” Rosenberg advises.