Radiology Coding Alert

Question: Which codes should I use for a report that states the physician used CT guidance for repeated aspiration attempts within a renal lesion through a percutaneous entrance site?

Iowa Subscriber

Answer: The appropriate codes for this procedure are 10022 (Fine needle aspiration; with imaging guidance) and 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation).

Caution: Although the report mentions a percutaneous entrance site, the physician documents an aspiration, so choose 10022 rather than 49180 (Biopsy, abdominal or retroperitoneal mass, percutaneous needle).

ICD-9: A lesion -- in this case, in the kidney -- can mean a lot of things. These range from malignant or benign processes to abscesses, cysts, or even a normal but hypertrophied portion of the kidney. You should never assume that a mass is a neoplasm. If you complete your claim before a firm diagnosis is established, the most  appropriate diagnosis choice will be 593.9 (Unspecified disorder of kidney and ureter).