Percutaneous procedures are little difficult to code. We have seen some of the procedures like Fine needle aspiration, arthrocentesis, Breast biopsy, myelogram etc. always have a primary procedure code followed by a imaging guidance or Radiological supervision and interpretation (RS&I) code. Since, interventional radiology charts includes multiple CPT codes for most of the procedures, hence the coders have difficult in perfectly coding the medical reports. We are here to discuss the abscess drainage CPT codes which are very common in diagnostic radiology coding. We have already learnt about ultrasound guidance CPT code 76492, which is used mainly for non-vascular procedure. Same way, we have a RS&I CPT code 75989, used in non-vascular region and used only with drainage CPT codes. Let use checkout more about this code.
Procedure performed for Abscess Drainage CPT codes
For drainage of an abscess, usually fluoroscopic, ultrasound or CT guidance is used percutaneously with the help of a drainage catheter. Once the abscess is located, the skin is punctured or access is taken through the skin (percutaneous) with a needle. Then a guidewire is passed to place a drainage catheter into the abscess cavity. The tract is dilated for the proper placement of the percutaneous drainage catheter. The drainage catheter or tube is secured to suction drainage. CPT code 75989 is reported only when the radiological supervision and interpretation is performed for the abscess drainage procedures.
CPT code 75989 : Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation
CPT code 10060 : Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
10061 ; Complicated or multiple
CPT code 10080 : Incision and drainage of pilonidal cyst; simple
CPT code 10160 : Puncture aspiration of abscess, hematoma, bulla, or cyst
CPT code 10180 : Incision and drainage, complex, postoperative wound infection
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Do and Don’t for CPT code 75989
Do not use CPT code 75989 along with Thoracentesis procedure codes (CPT codes 32554 and 32555) and Plueral drainage percutaneous procedure (CPT code 32556 and 32557) codes
Do not report CPT code 75989 along with CPT code 10030, image guided drainage of abscess, hematoma, seroma, lymphocele or cyst for soft tissues, percutaneously.
For open incision and drainage (I and D) procedures, use CPT code 10060 and 10061. Do not report CPT code 75989, along with these CPT codes.
Do not report CPT code 75989 along with CPT code 47490, Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation.
Do not report CPT code 75989 along with CPT code 49405, Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous
Do not report CPT code 75989 along with CPT code 49406, Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous
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Do not report CPT code 75989 along with CPT code 49407, Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal
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Sample Report for Abscess and Drainage Procedure
CLINICAL DATA: 48-year-old female with history of a chronic
intermittent pelvic and right lower quadrant pain. Prior CT and
ultrasound imaging demonstrates a circumscribed anechoic fluid
collection in the right aspect of the utero vesicular recess.
Patient has had several prior surgeries and there is concern for
pelvic inclusion cyst versus small focal abscess. Transvaginal drain
placement is warranted.
EXAM: ULTRASOUND GUIDED ABSCESS DRAINAGE
1. Placement of an 8.5 French percutaneous drainage catheter via a
transvaginal approach with ultrasound guidance
Moderate (conscious) sedation was used. 3 mg Versed, 150 mcg
Fentanyl were administered intravenously. The patient’s vital signs
were monitored continuously by radiology nursing throughout the
Sedation Time: 20 minutes
Informed consent was obtained from the patient following explanation
of the procedure, risks, benefits and alternatives. The patient
understands, agrees and consents for the procedure. All questions
were addressed. A time out was performed.
The thighs and benign item were sterilely prepped and draped in
standard fashion using Betadine skin prep.
Transvaginal imaging was then performed confirming the location of
the cyst just posterior to the bladder. A disposable peel-away
guided was then fashioned and attached to the transvaginal probe.
Local anesthesia was then attained by infiltration of 9 mL 1%
lidocaine using a 20 gauge x 20 cm Chiba needle.
Subsequently, an 8.5 French cook all-purpose drainage catheter was
advanced through the anterior fornix of the vagina and into the
fluid collection using trocar technique and real-time sonographic
guidance. The drainage catheter was then advanced off the trocar and
formed within the fluid collection. Aspiration yielded approximately
15- 20 mL clear serous fluid. A sample was sent for culture.
The peel-away guide was removed. The drainage catheter was connected
to JP bulb suction.
Technically successful placement of an 8.5 French transvaginal
Aspirated fluid is clear and serous. A sample was sent for culture.
CPT code :49407