General Surgery Coding Alert

When the surgeon performs a puncture aspiration to destroy a breast cyst, he inserts a needle into the cyst and withdraws the fluid contained in the cyst. He may then send the fluid to the lab for biopsy, depending on the cyst's nature. The patient's history will usually determine the surgeon's decision to have the cyst fluid evaluated. The procedure's primary purpose, however, is to treat the cyst, not to biopsy the contents.

If your doctor performs a puncture aspiration, you should report 19000 (Puncture aspiration of cyst of breast) and +19001 (... each additional cyst [list separately in addition to code for primary procedure]), says Melanie Witt, RN, MA, CPC, a surgical coding expert based in Fredericksburg, Va.

Use 19001 when the surgeon performs more than one puncture aspiration on the same breast, and always use 19001 in addition to 19000. If the physician aspirates a cyst from each breast, you should report 19000-50 (Bilateral procedure), Witt adds.