Radiology Coding Alert

Question: A patient had a drainage catheter placed three days ago for a postoperative subhepatic abscess. They called in the radiologist to do an assessment because patient condition changed. The radiologist injected the catheter under fluoroscopic guidance and documented the abscess cavity size with no fistula noted. How should we report this service?

Colorado Subscriber

Answer: You should report the injection service using 49424 (Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube [separate procedure]).

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

The appropriate code for a subhepatic abscess is 567.22 (Peritoneal abscess). FYI: The ICD-10-CM code for a subhepatic abscess is the similarly defined K65.1 (Peritoneal abscess).