Radiology Coding Alert

Question: Our physician did a sclerosis of a lymphocele. The procedure note reads as below:

“Intravenous access was established, the skin was cleansed with Betadine and 1% buffered lidocaine was used for superficial and deep anesthesia. CT scan was performed with the patient in supine position and images acquired through the pelvis for localization and comparison to previous examinations. A needle was advanced with CT guidance. Fluid was collected from the lymphocele for microbiologic testing followed by the instillation of 300 mg of doxycycline. The patient was observed on the table following the procedure without untoward effect. The needle was left in place and the patient was transferred to the nursing unit. After approximately 1 hour, an additional 200 mg of doxycycline was injected into the lymphocele cavity. Upon completion, the fluid was aspirated and discarded. Repeat CT images through the lesion demonstrate no evidence for extravasation or hemorrhage. Two-hour recovery phase performed in the nursing unit. Vital signs monitored throughout this phase were stable.”

Please help us to report this procedure.

New York Subscriber

Answer: There is no direct code for sclerosis of a lymphocele. In sclerotherapy, a sclerosing agent is injected into the cavity or sinus. This helps to harden the tissues and obliterate the cavity. Hence, you can report sclerotherapy with an injection procedure code. The best code for the procedure you have described can be 20500 (Injection of sinus tract; therapeutic [separate procedure]).

For the radiological examination and supervision, you report code 76080 (Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation).

Since your physician is also obtaining a sample for microbiological examination to establish a diagnosis, you can report code 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation) for the CT guidance.