Ultrasound guided aspiration seroma cpt code 2016 printable pdf file

[Pages:5]Ultrasound guided aspiration seroma cpt code 2016 printable pdf file

Ultrasound guided aspiration seroma cpt code 2016 printable pdf file

Sclerotherapy involves injecting a solution (often saline) into blood or lymphatic vessels supplying a lesion. The flow of blood or lymph is redirected, and the lesion shrinks or disappears. Sclerotherapy of a fluid collection is newly recognized in 2016 CPT? as 49185 Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous,

including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed. Reporting the Procedure Fluid-filled lymphoceles and seromas can result from surgery, and cysts may form, as well. Data suggests that placing drains during surgery

can help to prevent the lesions, but unlucky patients may still develop them. Code 49185 describes sclerotherapy for fluid collection of a lymphocele, cyst, or seroma, etc., and includes related contrast injection, diagnostic study, imaging guidance, and radiological suction and irrigation. There are other sclerotherapy codes in CPT?, such as those

reported for esophageal and gastric varices, hemorrhoids, and veins, but 49185 solely reports using the technique for fluid collections. Report one unit of 49185 per treated lesion. Append modifier 59 Distinct procedural service to the second and subsequent units. Report a single unit of 49185 for connected lesions. Example: Mary Louise wondered

what she'd done to deserve the pain around her brand new kidney. After enduring dialysis for so many years, was her weeks-old organ already letting her down? Mary Louise's lab results were fine for a recent transplant recipient. Her physician thought she felt a lump while palpating the area around the kidney. A quick ultrasound confirmed

suspicion: Mary Louise had a large lymphocele in her retroperitoneal area, and it was compressing the kidney. Mary Louise, relieved at the explanation, consented to treatment. During surgery, the physician removed the fluid from the lymphocele with a needle. She then injected the sclerosant and placed Mary Louise in various positions to assure all

walls of the cavity were exposed. The sclerosant was removed, and the procedure was performed again. The pain and the lymphocele eventually disappeared, and Mary Louise rested easy. ICD-10: I89.9 Disease of lymphatic vessels NOS CPT?: 50390 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous 49185 ? 51 Multiple

procedures CPT? gives you two choices when introducing a needle: 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst and 50390. 49185 Isn't Collection Be careful not to confuse sclerotherapy with collection or drainage; 49185 doesn't include drainage of fluid prior to sclerotherapy treatment. According to the American Medical

Association's (AMA's) 2016 CPT? Changes: An Insider's View, drainage represents separate work and should be reported with the drainage procedure code for that particular anatomical site. You may report sclerotherapy and collection/drainage if performed on the same lesion, just as Mary Louise's physician separately reported her services. Bottom

line: If an injection was made for collection or a drainage tube was inserted, that's a separate service. For payers who accept it, append modifier 51 to the collection/drainage code to identify it as the secondary procedure performed that same day. Brad Ericson, MPC, CPC, COSC, is director of publishing at AAPC and a member for the Salt Lake City,

Utah, local chapter. Director of Publishing at AAPCBrad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor.He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in

Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City. Uniquely Code Sclerotherapy of Fluid was last modified: February 1st, 2016 by Brad Ericson Anyone who has worked in any portion of the medical field has had to learn at least a little bit about CPT codes. These

Current Procedural Terminology codes are used to document and report medical procedures. Take a look at this guide to learn information about CPT codes.What Is a CPT Code?Current Procedural Terminology codes -- or CPT codes -- are alphanumeric codes used to document and report surgical, medical and diagnostic procedures. These codes are

used by doctors and insurance companies so that procedures are charted correctly in a concise way. To succeed in CPT code training, you must understand medical terminology, insurance payer rules, procedure bundling rules, anatomy and modifier usage. The AAPC Coder offers a complete list of current CPT codes that you can search with just a

keyword.Category 1 CPT codes are six separate types of five-digit numeric codes. These include evaluation and management, pathology and laboratory, medicine, radiology, surgery and anesthesiology. These five-digit codes cover most procedures performed in a medical practice. Category 1 CPT codes are also used to identify procedures that are

approved by the Food and Drug Administration.Category II CPT CodesCategory II CPT codes are alphanumeric codes that provide additional information along with the Category I CPT code. These codes are often used to record a number of procedures that are used in combination with a main procedure. For example, when heart failure is assessed

there are several procedures provided to the patient. From taking blood pressure, weight and level of activity to observing the clinical signs of volume overload, all of these procedures are kept track of with Category II CPT codes.Category III CPT CodesThe last category of CPT codes cover emerging or experimental services, technology and

procedures. These codes are temporary but allow you to be more specific when coding while helping to track how effective a new medical procedure or technology has become. Because some of these new or experimental procedures fail, the Category III CPT codes change constantly, and they become permanent only when added to the Category I

CPT codes.Where to Practice Using CPT CodesCPT coding training opens doors when it comes to jobs in the medical coding and billing fields. Learn CPT diagnosis codes and take the CPT coding practice test right online at places like Practice Quiz or Career Coders. These websites offer practice tests for anyone seeking to improve their knowledge or

gain confidence in their CPT coding skills. MORE FROM By Terri Brame, MBA, CHC, CPC, CPC-H, CPC-I, CGSC A review led by the American Medical Association's CPT? Editorial Panel last year showed that codes for the surgical portion of percutaneous fluid drainage procedures were being reported with the codes for

imaging supervision and interpretation (S&I) more than 75 percent of the time. Based on this review, the consensus reached was that a single code representing both services may be more appropriate. As a result, CPT? 2014 brings major changes for reporting percutaneous fluid drainage by catheter. Many Changes to 2014 Coding Several drainage

codes were deleted for CPT?2014 and replaced by only a handful of new, more inclusive codes. Deleted CPT? codes, effective Jan. 1, 2014: 32201 Pneumonostomy; with percutaneous drainage of abscess or cyst 44901 Incision and drainage of appendiceal abscess; percutaneous 47011 Hepatotomy; for percutaneous drainage of abscess or cyst, 1 or

2 stages 48511 External drainage, pseudocyst of pancreas; percutaneous 49021 Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous 49041 Drainage of subdiaphragmatic or subphrenic abscess; percutaneous 49061 Drainage of retroperitoneal abscess; percutaneous 50021 Drainage of perirenal or

renal abscess; percutaneous 58823 Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous (eg, ovarian, pericolic) New codes were created specifically to describe draining fluid collections by catheter, defined within the code descriptors as an abscess, hematoma, seroma, lymphocele, cyst, or other similar contained fluid

collection. New CPT? codes, effective Jan. 1, 2014: 10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous 49405 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg,

kidney, liver, spleen, lung/mediastinum), percutaneous 49406

peritoneal or retroperitoneal, percutaneous 49407

peritoneal or retroperitoneal, transvaginal or transrectal Note: Code 49407 requires the needle or catheter to be passed through the vagina or rectum to reach the fluid collection within the rectum. This code is not reported for

draining fluid from the vagina. Percutaneous fluid drainage involves inserting a large bore needle or catheter into fluid collection to drain that fluid. The device is often left in place to allow continuous fluid drainage, as needed. Because the procedure is performed without an open approach, many physicians use imaging--including fluoroscopy,

ultrasound, computed tomography (CT), or magnetic resonance imagery (MRI)--to guide the needle insertion and confirm the needle accesses the fluid. S&I of the imaging is always included. Never report the following radiologic S&I CPT? codes with percutaneous image-guided fluid collection drainage codes: 75989 Radiologic guidance (ie,

fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation 77002 Fluoroscopic

guidance for needle placement (eg, biopsy, aspiration, injection, localization device) 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection,

localization device), radiological supervision and interpretation 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation Percutaneous image-guided fluid collection drainage codes may be reported once for each fluid

collection drained, but may not be reported more than once per fluid collection, regardless of the number of times the fluid collection is accessed. Clinical Scenario 1 Indications: A 67-year-old patient presents with fever and left, upper-quadrant pain increasing over the past 36 hours. The pain is not associated with eating a meal or other event.

Patient has known cirrhosis secondary to alcoholism. CT indicates a right hepatic abscess. Procedure: The physician identifies the right hepatic lobe abscess using imaging guidance. The abscess is accessed using a guidewire. The physician aspirates purulent material, which is sent for culture. The access point is dilated to allow placement of a

drainage catheter, which is sutured in place without complication. Coding: 49405 Clinical Scenario 2 Indications: A pediatric patient with a history of chronic throat infections presents with continued swelling and pain in the neck, not associated with a current infection. The physician suspects retropharyngeal abscess secondary to lymph node

breakdown, versus cellulitis. CT confirms there is an abscess. Procedure: Using CT imaging, the physician identifies the retropharyngeal abscess and enters the fluid collection with a guidewire. Purulent material is aspirated and sent for culture. The access point is dilated to allow placement of a drainage catheter, which is sutured in place without

complication. The patient is kept inpatient until the drain can be removed. Coding: 10030 New Codes Apply to Percutaneous Drainage, Only The new codes only apply to percutaneous drainage by catheter and certain transvaginal and transrectal drainages. Many new parenthetical instructions have been added to CPT? to redirect you to other

drainage codes. In all, CPT? added or revised 30 parenthetical notes regarding correct coding for fluid drainage. For example, following 49407, parenthetical notes direct the coder to thoracentesis, percutaneous pleural drainage, open drainage, and peritoneal drainage codes. CPT? retains existing codes to report specific percutaneous procedures.

For example, percutaneous cholecystostomy (creating a surgical opening in the gallbladder using a percutaneous approach) is still reported using 47490 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation; and cavity

drainage is still reported with codes for thoracentesis (32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance, 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) and abdominal paracentesis (49082 Abdominal paracentesis (diagnostic or therapeutic); without

imaging guidance, 49083 Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance). Terri Brame, MBA, CHC, CPC, CPC-H, CPC-I, CGSC, is the compliance education officer for the University of Arkansas for Medical Sciences. She is also the author of E&M Coding Clear & Simple, Evaluation & Management Coding Worktext,

published by F.A. Davis, the Taber's Cyclopedic Medical Dictionary publisher. Brame is a member of the Little Rock Central, Ark., local chapter, and a past local chapter president. John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999.

He is an alumnus of York College of Pennsylvania and Clemson University. CPT? 2014 Groups Drainage Codes with S&I was last modified: April 1st, 2014 by John Verhovshek

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