Coding for incision and image-guided fluid collection drainage by catheter

Q.

What documentation does my doctor need to dictate to allow reporting of CPT^® codes from the 49405–49407 series as opposed to CPT code 10160? 

A.

CPT odes 49405–49407 are specified as “drainage.” According to the AMA, “drainage” requires placement of an indwelling catheter. If the fluid is removed via needle or catheter that is not left in place, then the procedure is considered “aspiration” and not drainage. The key factor in determining correct CPT code assignment is for the provider to clearly document whether a catheter was left in place or not at the termination of the procedure. 

The codes and full descriptions are as follows:

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

49406 Image-guided fluid collection drainage by catheter (e.g., abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous

49407 Image-guided fluid collection drainage by catheter (e.g., abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal

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