Cyst Aspiration

Cyst Aspiration

A needle is placed with imaging guidance into the cyst to aspirate its contents. 

The most commonly involves cysts aspiration procedures are described below

1. Breast Cyst Aspiration

CPT 19000 - Puncture aspiration of cyst of breast 

CPT 19001 - Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure)

Procedure description:

The patient is appropriately prepped and anesthetized by local anesthesia, the physician inserts a sterile needle into the cyst using imaging guidance. He then withdraws the fluid from the cyst. Finally he ensures hemostasis.

If imaging guidance is performed, use 76942 (Ultrasonic guidance for needle placement,  imaging supervision and interpretation ) or 77021 (Magnetic resonance guidance for needle placement, radiological supervision and interpretation )

2. Baker's cyst aspiration 

CPT 10160 - Puncture aspiration of abscess, hematoma, bulla, or cyst 

For imaging guidance, Check 76942, 77012, 77021 

Procedure description:

The patient is appropriately prepped and anesthetized by local anesthesia, the physician inserts a sterile needle into the cyst using imaging guidance. He then withdraws the fluid from the cyst. Finally he ensures hemostasis.

3. Bone cyst aspiration

CPT 20615 - Aspiration and injection for treatment of bone cyst

Procedure description:

The patient is appropriately prepped and the area anesthetized, the physician inserts a sharp needle through the skin into the bone cyst. Using a syringe, he aspirates the bone cyst to drain it of any fluid or purulent material inside. He submits a sample to a laboratory for inspection. Finally he ensures hemostasis.

4. Liver, kidney, spleen, lung/mediastinum cyst aspiration

CPT - 49405 - Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous 

 Procedure description:

 The patient is prepped and sedated, the physician locates the fluid collection to be drained and uses imaging to guide percutaneous placement of a catheter to provide continuous drainage of that fluid collection, such as from an abscess. The service may also include catheter maintenance and eventual removal of the catheters.  

Moderate sedation is included.

Do not report CPT 49405 in conjunction with any guidance 75989, 76942, 77002, 77003, 77012, 77021.

5. Ganglion cyst aspiration

CPT  20612 - Aspiration and/or injection of ganglion cyst(s) any location 

For multiple ganglion cyst aspirations, use 20612 and append modifier 59

6. Thyroid cyst aspiration

CPT  60300 - Aspiration and/or injection, thyroid cyst 

For imaging guidance, use 76942 or 77012

7. Pancreatic pseudocyst aspiration

Use CPT 49405 - Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous

8. Renal cyst Aspiration

CPT 50390 - Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous 

For radiological supervision and interpretation, see 74425, 74470, 76942, 77002, 77012, 77021

CPT 74425 - Urography, antegrade (pyelostogram, nephrostogram, loopogram), radiological supervision and interpretation

CPT 74470 - Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation 

For Fine Needle Aspiration use 10022 with imaging guidance and use 10021 for no imaging guidance.

Thoracentesis

Thoracentesis

Thoracentesis is the process of removing the excess plural fluid. Fluid accumulates in the pleural space, the area between the lung and the chest wall.

 Drainage of plural fluid can be performed using needle or catheter and the coding of the procedure is dependent on the technique.

 Below are the procedure codes for Thoracentesis,

CPT: 32555 - Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance
 

Procedure Description:

The patient is placed in a seated position and slightly leaning forward with the arms resting on small table. the patient is appropriately prepped and anesthetized, the physician inserts a thin needle or catheter between the ribs into the space between the lungs and chest wall using imaging guidance,  He removes the fluid or blood from the chest cavity through the needle and sends it to the laboratory for investigation. After the provider drains the fluid, blood, or air, he close the site.

CPT 32555 includes imaging guidance, so it is  not separately reportable

CPT: 32557 - Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance

Procedure Description:

The physician uses imaging (ultrasound or CT) to locate the fluid to be drained from the chest. He preps the site and injects a local anesthetic into the catheter insertion area. He use a needle to access the fluid collection under imaging guidance and then pass a guidewire into the pleural space. The physician replace the needle with a dilator to create room for the catheter. He then replaces the dilator with the catheter. Once he properly positions the catheter in the space, he secures the tube in place such as by stitches. He connects the external end of the tube to a suction drainage system. He dresses the puncture site.
 

If the provider does not use imaging guidance, then assign 32556.

CPT 32556 - Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance 

Procedure Description:

The patient is prepped and anesthetic, He makes a small incision between the ribs to pass the catheter through the skin. He then passes the catheter into the chest without imaging guidance. He secures the tube in place such as by stitches. He connects the external end of the tube to a suction drainage system. He dresses the puncture site.

For insertion of indwelling tunneled pleural catheter with cuff, use 32550

CPT: 32550 - Insertion of indwelling tunneled pleural catheter with cuff 

Procedure Description:

The patient is appropriately prepped and anesthetized, the physician makes an incision in the chest and inserts a hollow needle into the pleural space. he inserts a guide wire through the needle. he then removes the needle and leaves the guide wire in place. The physician then makes a second incision and passes a tunneling device with the catheter subcutaneously, from the second incision until it exits through the original incision site. he advances the catheter using the tunneling device until the cuff is buried just under the second incision. The physician then feeds a dilator over the guide wire into the pleural space, inserts the catheter, and secures it. he leaves the chest tube in place with one end exiting the body for connection to a collection container. The chest tube helps re–expand the lungs if necessary and allows for drainage of air, blood, or fluid. The physician closes the original upper incision with staples or stitches

If imaging guidance is used, then assign 75989

CPT: 75989 - Radiological guidance (Eg, fluoroscopy, ultrasound, or CT), for percutaneous drainage  with placement of catheter, radiological supervision and interpretation

Use CPT 32552 for removal of an indwelling tunneled pleural catheter with cuff.

CPT: 32552 - Removal of indwelling tunneled pleural catheter with cuff 

Procedure Description:
The provider  uses local anesthetic. He makes an incision into the skin over the catheter, frees the catheter from the skin, and gently pulls back the catheter out of the pleural space. The physician cleans the incision site with antibiotics and applies the dressing

CPT: 32551 - Non-tunneled indwelling chest tube without cuff for abscess or effusion

Procedure Description:

The patient is appropriately prepped and anesthetized, the physician uses a trocar to make an incision on the chest wall near the fifth intercostal space and enters the pleural cavity. The physician then inserts a hollow plastic tube between the ribs and into the chest to draw out fluid or air from and around the lungs. The physician sutures the skin to keep the tube in place. The physician may attach the free end to an underwater seal, which allows drainage of fluid and air from the chest. The provider uses this technique in cases of pneumothorax and pleural effusion.

Use appropriate E&M code for removal of an indwelling non-tunneled chest drainage catheter.

 

Tendon Sheath or Tendon Origin Injections

Tendon Sheath or Tendon Origin Injections

Tendon Sheath or Tendon Origin Injections involve the injection of steroids into the tendon sheath to reduce pain and inflammation. Injection is performed with x-ray or ultrasound guidance.

CPT 20550 - Injections; single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") 

Procedure Description:

After administration of adequate anesthesia and prep and draped, the physician locates the injection site. The appropriate amount of corticosteroid, anesthetic, or anti–inflammatory drug is then injected into the aponeurosis of the tendon sheath and/or ligament.

CPT 20551 - Injections, single tendon origin/insertion  

Procedure Description:

The patient is appropriately prepped and the area anesthetized, the physician prepares the site for injection. he may use radiological guidance to identify the tendon origin when it is not possible to visually locate the site of drug delivery. he injects the appropriate amount of corticosteroid, anesthetic, or anti inflammatory drug directly at the tendon origin or insertion and then withdraws the syringe. 

Notes:

Use code 20550 for injection of the plantar aponeurosis.

Single or multiple injections into the same ligament or tendon at different sites are coded as one.

For single or multiple injections into multiple ligaments, use multiple procedure codes.

Report the Bilateral procedure injections as 20550 with 50.

Trigger Point Injections

Trigger Point Injections

Trigger point injections involve selective injection of a very small amount of anesthetic agent and
steroids into areas of pain, usually in the back, to relieve pain. Injections are made into muscles, and
coding is determined by the number of muscles injected.

Procedure description:

The patient is appropriately prepped and the area anesthetized, the provider palpates, or touches, the muscle to determine the location of a trigger point. he applies firm pressure to the trigger point to assess for referred pain and a twitch response. Then, he slowly injects the appropriate amount of corticosteroid or anesthetic into the trigger point.

CPT 20552 - Injections, single or multiple trigger points, 1 or 2 muscles 

CPT 20553 -  Injections, single or multiple trigger points, 3 or more muscles

If imaging guidance is performed, see 76942, 77002, 77021 

CPT 76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT 77002 - Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

CPT 77021 - Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

Notes:

These codes are based on the number of muscles injected. Consider as two if paired muscles
are injected.

Guidance is coded once per patient encounter, regardless of the number of regions treated.

IINTERVENTIONAL RADIOLOGY – Vascular Procedures

 Interventional Radiology – Vascular Procedures

                Vascular procedure consist of two major parts Surgical and Radiological S&I

First part: Surgical codes

      1.       Vascular access

      2.       Catheter placement

      3.       Interventions Š

Second part: Radiological supervision and interpretation

     1.       Imaging (guidance and images taken)

     2.       Interpretation of films

     3.       Physician must supervise and interpret to assign S&I codes.


In case physician performs only the S&I part alone - Append Modifier -52


In Medical Coding - Five vascular systems for interventional procedures:

         1.       Arterial

         2.       Venous

         3.       Pulmonary

         4.       Portal

         5.       Lymphatic


Components of IVR

         1.       Catheter insertion point Š

         2.       Catheter end point Š

         3.       Vessels catheterized Š

         4.       Vessels visualized Š

         5.       Abnormal anatomy findings

Access Site       

      1     Where physician enters the vascular system by puncturing a vessel Š

      2     Multiple access sites and their catheterizations are reported separately

Vascular Family

     Network of vessels that arise from a single branch from the aorta or vena cava

        Š  First Order - Vessel that is a primary branch off the aorta or vena cava Š

          Second Order - Vessel branching from a first order vessel Š

          Third Order - Vessel branching from a second order vessel

Non-Selective Catheterization - The catheter or needle is placed directly into an artery or vein (and not moved or manipulated further) or is placed only into the aorta (thoracic and/or abdominal) from any approach.

Selective Catheterization - Movement of the catheter into the arterial or venous system beyond the aorta or vena cava

Catheterization Coding Rules Š

                Code each vascular family to the highest order selected. Š

                Each vascular access is coded separately. Š

                Additional vascular families catheterized are coded separately.

                Each family is coded separately when two or more vascular families are catheterized.


Additional Branches in Same Family

                Only 1 initial catheter placement code can be reported per vascular family. Š

                Catheter may be pulled back and advanced into a different branch within the same family. Š

                Code (36218 or 36248) (36012) for the lower of the two placements in addition to the highest catheter placement code in the family  36218 and 36248 may be assigned multiple times.


Supervision & Interpretation Coding Š

               Contrast is injected for imaging of vessels Both unilateral and bilateral codes Š

                Some codes specify selective imaging Š

               S&I codes are assigned for each vessel studied Š


Modifiers usage Š

               Do not use modifier 50 or RT/LT with Vascular catheterization codes.

               Use modifier 59 to indicate separate vascular families. Š

               For S&I codes – RT/LT or 59 when applicable

Catheter Placement - Aorta

      1.       When catheter placement in aorta and contrast flows into lower extremities – runoff

               Assign CPT = 36200 and 75630 Š

      2.       When catheter placement in abdominal aorta and catheter repositioned in lower aorta for a lower extremity study

               Assign CPT = 36200, 75625, 75716

Example: Š


       Access: Femoral Artery then catheter advanced to aorta, contrast injected with imaging. Catheter advanced to the right common iliac, contrast injected with imaging of the right lower extremity and right internal iliac.

   36245 (R C Iliac)

   75625 (Aortogram)

   75710 (RLE) Š

    Access: Femoral Artery then catheter selectively advanced to the bilateral internal iliacs and bilateral uterine arteries with contrast injection and imaging.

     36247 (RUA)

     36247-59 (LUA)

     75736-RT (R Iliac)

     75774 (RUA)

     75774 (LUA)

     75736-LT (L Iliac)

    Access: Right Common Femoral then catheter advanced to the aorta, injection performed for aortogram. Catheter advanced to the left renal with injection an imaging, then advanced to the right renal with injection and imaging. SMA is selectively catheterized with injection and imaging.

       36245 (L Renal)

       36245-59 (R Renal)

       36245-59 (SMA)

       75724 (bilateral renal)

       75726 (SMA)


     Access: Right Common Femoral then catheter advanced to the aorta, injection performed for aortogram. Catheter advanced to the celiac with injection and imaging, then advanced to the right hepatic with injection and imaging, then advanced to the left hepatic with injection and imaging.

       36247 (R hepatic)

       36248 (L hepatic)

       75726 (Celiac)

       75774 (R hepatic)

       75774 (L hepatic)


Therapeutic Interventions:

     1.       Angioplasty

     2.       Stents Š

     3.       Atherectomy Š

     4.       Embolization Š

     5.       Thrombolysis Š

     6.       Thrombectomy Š

     7.       Dialysis Graft Declotting


NOTE:

Diagnostic angiography codes should not be used with interventional procedures for:

  Contrast injections, angiography, road mapping, and/or fluoroscopic guidance for the intervention,    Vessel measurement, and post-angioplasty/stent angiography as this work is captured in the interventional radiologic supervision and interpretation code(s).


Stent Placement

          Angioplasty performed solely to deploy a stent is not separately coded.


Atherectomy

           Report one Atherectomy per vessel

           Do not report an angioplasty when a positioning balloon is utilized for Atherectomy.


Embolization

           Embolization code is assigned once per operative field.

INTERVENTIONAL RADIOLOGY - INTRODUCTION

INTERVENTIONAL  RADIOLOGY

INTRODUCTION:

1.  INTERVENTIONAL RADIOLOGY is a medical sub specialty of Radiology that uses minimally invasive image-guided procedures to diagnosis and treat diseases in nearly every organ system.

    Classified into Vascular procedures and non vascular procedures.   

CPT’s: TWO COMPONENTS

1  SURGICAL CODES – Describe the work of actually performing the intervention such as inserting catheters or needles, inflating balloons, deploying stents, etc.

2  RADIOLOGICAL S&I CODES - Describe the work of taking x rays, performing image guidance, and the processing and interpreting of the images. 

VASCULAR PROCEDURES –TYPES

1  NON SELECTIVE PROCEDURES

       When the catheter stays in the vessel entered or only advances to the aorta. 

2  SELECTIVE PROCEDURES

      When the catheter advances from the vessel entered or from the aorta into a branch vessel.

INCLUSIVE:

1  Regardless of the approach (arm/leg) once the aorta is entered and a branch is selected – a selective catheter placement code must be used and the non-selective catheter position is included.

2  If you had to go through a section of a vessel to get to a more selective vessel the catheter placement in the initial vessel is included in the higher order selection as well as non selective placement.

EG:  3^rd order includes 2^nd and 1^st order as well as non selective placement.

SAMPLE CHART

A catheter is placed in the right femoral artery, it is advanced to the abdominal aorta(36200) contrast is injected, and imaging of the abdominal aorta is performed(75625) the catheter is advanced into the left common iliac artery(36245) and images taken of the entire left lower extremity of the foot (75710). The catheter is then advanced into the left superficial femoral artery (36247) and additional images are obtained to further evaluate the Tibial vessels (75774)

  36247- (Left superficial femoral artery) (Final placement includes lesser first order selection 36245 and non-selective 36200)

  75625-(Abdominal aorta), 75710 (Unilateral extremity) 75774 (for the additional selective imaging of the Tibial vessels)   

2 access site:

A sheath and guidewire are placed in the right femoral artery (36140). The guidewire will not advance to the aorta. An injection of the right femoral artery through the sheath is performed showing occlusion of the right common iliac. Right leg runoff angio is then completed. The right side is abandoned and access is gained through the left femoral artery. The catheter is advanced into the abdominal aorta at the L2 level (36200). Contrast is injected, and imaging of the abdominal aorta is performed (75625). The catheter is pulled down to L4 and left leg runoff done (75716).

  36140-59(right sided access), 36200(left sided access)

  75625 (abdominal aorta), 75716(Bilateral runoff)

ADD ON CODES:

There are 2 codes that describe the coding of each additional second order, third order, and beyond selective catheter placement in the same vascular family. 36218 and 36248.

As vessels are get more selective each lower level is passed through is included in the final destination.

Some vessels can only be selected by pulling the catheter back and going a different route in the same vascular family.  This is where additional second or higher selective catheter position codes 36218 & 36248 apply. 

SAMPLE CHART:

A catheter is placed in the right femoral artery. It is advanced to the high abdominal aorta, and an aortogram is performed (36200, 75625). The catheter is advanced into the common hepatic artery for additional selective imaging (add 36246, 75774) the catheter is withdrawn from the common hepatic artery and placed in the splenic artery for additional selective imaging (36248, 75774).

  36246 (Common hepatic), 36248 (splenic)

  75726 (Celiac), 75774 (Common hepatic), 75774(splenic) 

                 

DO AND DON’T

  Do code to where the tip of the catheter is.

  Do code each individual vascular family separately with the same rules using- 59 modifiers as necessary.

  Do code each approach from a different access site separately.

  Do code the aorta placement (36200) instead of other non-selective codes if the aorta has been entered.   

  Do use code 36251-36254 for unilateral or bilateral selective or superselective renal angiography. These codes include catheter placements, renal S&I, accessory renal catheter placements and S&I, non-selective abdominal aortography, 3D reconstructions and pressure gradient if obtained.

  Do use codes 36222- 36228 for selective or superselective cervicocerebral angiography. These codes include catheter placements, cervical carotid, cerebral carotid, vertebral, intracranial and external carotid supervision and interpretation, as well as non-selective arch aortography.

  Do not code imaging codes for injecting small amounts of contrast to localize a vessel for subsequent selection.

  Do not code the access site separately once a catheter through the sheath has reached the aorta or selected another vessel.