Coding for catheter removal after drainage of transplant kidney fluid collection

Q.

The doctor placed a drainage catheter to drain a transplant kidney fluid collection. However, after the fluid was drained, the catheter was removed, all in the same session. I understand the drainage codes require an indwelling catheter. Should we report 49405-52 or as an aspiration?

A.

You are correct in that if the catheter is not left in place for continued drainage, it is considered an aspiration, not a drainage. You cannot report a drainage code in this case, even with modifier 52. Some recommend 10160, even though that is in the integumentary system section of CPT^®.

The codes and full descriptions are as follows:

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

Your only other choice would be an unlisted code for the body area such as 49999.

49999    Unlisted procedure, abdomen, peritoneum and omentum

In either case, be sure to report the CT guidance separately – 77012.

77012    Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation