Sclerotherapy of Fluid Collection Coding

Sclerotherapy of Fluid Collection Coding

Code 49185 Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed describes sclerotherapy of a fluid collection, such as a lymphocele, cyst, or seroma, and includes related contrast injection, diagnostic study, imaging guidance, and radiological suction and irrigation. There are other sclerotherapy codes in CPT®, such as those reported for esophageal and gastric varices; hemorrhoids; and veins. But, 49185 solely reports using the technique for fluid collections.

You should report one unit of 49185 per lesion treated. Append modifier 59 Distinct procedural service to the second and subsequent units. Report a single unit of 49185 for connected lesions.

Do not confuse sclerotherapy with collection or drainage. Code 49185 doesn’t include drainage of fluid prior to sclerotherapy. According to AMA’s 2016 CPT Changes: An Insider’s View, drainage represents separate work and should be reported with the drainage procedure code for that particular anatomical site. You may separately report collection/drainage if performed on the same lesion (e.g., If an injection is made for collection or a drainage tube was inserted, that’s a separate service).

Brad Ericson

Brad Ericson

Director of Publishing at AAPC
Brad Ericson, MPC, CPC, COSC, has been director of publishing for more than 10 years. Before AAPC he was at Optum for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.
Brad Ericson

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Brad Ericson, MPC, CPC, COSC, has been director of publishing for more than 10 years. Before AAPC he was at Optum for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

One Response to “Sclerotherapy of Fluid Collection Coding”

  1. Sharon Costanzi says:

    Would this be the correct code for sclerotherapy of a hydrocele? I am seeing other online posts saying code 36470 would be the correct code.

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