Radiology Coding Alert

Question: How should I code the following report from the radiologist?

Technique: Real-time ultrasonic evaluation of the abdomen was performed. An appropriate site was selected for paracentesis ... 5-gauge Yueh catheter advanced into collection. A total of 6-ml straw-colored fluid obtained. The needle was removed.

Colorado Subscriber

Answer: For the abdominal paracentesis, you should report 49080 (Peritoneocentesis, abdominal paracentesis or peritoneal lavage [diagnostic or therapeutic]; initial).

A note with 49080 directs you to use 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for imaging guidance.

Watch out: CPT guidelines for diagnostic ultrasound state that ultrasound guidance procedures "require permanently recorded images of the site to be localized." You should not separately report 76942 without a permanently recorded image.

Unless your payer tells you otherwise, you may report 76942 for this scenario (which notes only "real- time ultrasonic evaluation") as long as you know a permanently recorded image is on file.