Wiki Help with IR procedure

[latonya78]

I am new to IR coding and would like some assistance with coding the following case. I would also appreciate any online resouces that will help me as I learn this complex speciality.

INDICATION: pseudocyst


TECHNIQUE: Risk of the procedure were discussed with the patient's mother

and she agreed to proceed with the procedure and consent was signed. The

patient was placed supine on the examining table and was IV sedated by

Pediatric Sedation Services. Ultrasound was performed over the upper

abdomen hand the multiloculated pseudocyst was seen. The skin was marked

directly over this lesion. This area was prepped and draped in a sterile

fashion. Local anesthetic was applied using 1% buffered Lidocaine. Small

skin incision was made. A 19-gauge Yueh needle was then advanced into the

fluid collection. Serous fluid was removed with a total of 50 mL removed.

The first several milliliters were sent to lab for cultures and

sensitivity. The needle was removed and a bandage applied. Follow-up

ultrasound demonstrated complete collapse of the pseudocyst. There were no

complications there was no significant blood loss.



COMPARISON: None



FINDINGS: Ultrasound demonstrating multiloculated fluid collection in the

mid upper abdomen. Ultrasound demonstrates needle entry into the

pseudocyst. Subsequent post procedure ultrasound demonstrates collapse of

the pseudocyst.



IMPRESSION: Successful ultrasound guided abdominal CSF pseudocyst

aspiration.


Here are the codes that I have come up with for this case, CPT 10022 and 76942. My co-worker came up with CPT code 49406.

Any assistance in this case is greatly appreciated.

Thanks,

 

[mzachel]

I would code 10160 for a needle aspiration for therapeutic purpose to remove the pseudocyst.

Do not code 76942 unless the images were saved for the records. (I have the physicians I code for state the images were saved to PACS -our imaging system in case there is ever a problem or audit, since I don't have access to the PACS system) If the physician didn't save the image you can't use the code since all diagnostic US codes require permanently recorded images per the CPT guidelines.

49406 should not be coded in this case. That code only applies to case where drainage is performed by catheter (the catheter can be left in place or removed at the end of the procedure)

Dr. Z is an excellant reference for IR coding, Medlearn publishing also has good referance material.

 

[latonya78]

Thank you.