Radiology Coding Alert

Question: If a paracentesis is performed and a repeated ultrasound during the procedure showed residual ascites into which a second needle was advanced, should we report the same code twice?

California Subscriber

Answer: No. Because both procedures occurred during the same session, the service is reported with 49080* (Peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; initial). However, if the ultrasound was conducted on a later date and paracentesis was performed then, the second service is assigned 49081* ( subsequent). The definition for subsequent indicates another encounter during the same episode of care. Current Correct Coding Initiative edits exclude the use of both 49080 and 49081 on the same date of service.

If imaging guidance is performed at either stage of the procedure, you should also report 76360 (Computerized axial tomographic guidance for needle biopsy, radiological supervision and interpretation) or 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) based on the modality used.