Dr. Z

Percutaneous Aspiration, Drainage, or Both?

Have you ever received a report to code where multiple services that each have separate CPT codes

seem to be described?

These can be confusing, and how do you arrive at the correct CPT option or options?

We at ZHealth see this scenario occur almost weekly and thought we would pass on the following

coding guidance based upon the clinical scenario.

Let’s say you receive a report in which the performing provider is asked to drain a pelvic abscess with

the placement of an indwelling catheter.

Prior to the placement of this indwelling catheter, the provider first uses imaging guidance and places a

needle into the abscess to verify correct position and draws some fluid out. This initial needle

placement can be looked at as being analogous to a “guiding-shot” when a transcatheter therapy

procedure like a stent placement, angioplasty, thrombolytic infusion, etc. is performed. In each of the

non-vascular and vascular scenarios just defined, before proceeding on to the main, planned

procedure, correct and precise anatomic localization must be verified. Once this verification is

confirmed, the primary procedure is performed.

Just like the confirmatory or positional injection(s)are not separately coded for as a “diagnostic”

angiogram, the removing of fluid via the needle placed in the abscess prior to the planned indwelling

catheter placement is not separately coded either.

In the scenario described above, to help arrive at the correct code, first consider what was ordered.

Was it an aspiration or a drainage?

Once you have answered that question, next focus on whether the drainage was performed using a

device that was left in place at the end of the procedure (i.e., an “indwelling” catheter”) or via a device

that was removed at the end of the procedure (this is defined as an aspiration).

If the device is left in the patient when they (the patient) leave the room/location where the drainage is

done, this is an indwelling catheter placement. CPT provides for use four (4) codes for the placement of

an indwelling catheter (all include imaging guidance, so don’t code for that separately!). These codes

are 10030, 49405, 49406 and 49407. They all describe different anatomic locations, so be certain to

pay close attention to “where” the drainage device was placed.

If the device (it can be the same device that might be used for the indwelling catheter placement) is

removed at the end of the procedure, this is an “aspiration” and would be defined by code 10160. This

code is not restricted to any anatomic area, so it can be assigned when this percutaneous aspiration

might be performed in variable locations throughout the body. Also, this code (10160) does not include

imaging guidance, so based upon the modality used (and assuming all documentation requirements

are met), don’t forget to assign that code (see 76942, 77002, 77012 or 77021) as well.

And the winner is…

So, in the scenario presented at the beginning of this article, when the main plan is to perform a

percutaneous image-guided abscess drainage of the pelvis, the correct code to assign is a single CPT

code, 49406. You should never code for both procedures when they are performed at the same patient

encounter for the same anatomic area.

FOR future reference, ensure to always verify the documentation to confirm the necessity of the procedure and adherence to coding guidelines.