General Surgery Coding Alert

Question: A patient presented for treatment of a painful Peritoneal Inclusion Cyst (PIC), which the surgeon treated using sclerotherapy. The surgeon inserted a transabdominal drainage catheter under ultrasound guidance, withdrew fluid and injected contrast. With contrast visualization, the surgeon identified a second PIC and proceeded to drain both cysts before instill sclerosing agent. Should we bill this as 49185 x 2, and can we separately bill the drainage or any other part of the service, such as ultrasound guidance?

Texas Subscriber

Answer: No, you should not bill two units of 49185 (Sclerotherapy of a fluid collection [e.g., lymphocele, cyst, or seroma], percutaneous, including contrast injection[s], sclerosant injection[s], diagnostic study, imaging guidance [e.g., ultrasound, fluoroscopy] and radiological supervision and interpretation when performed). A CPT^® text note following the code states, “For treatment of multiple interconnected lesions treated through a single access, report 49185 once.”

You cannot separately bill for listed elements in the code descriptor, such as contrast injection, imaging guidance, and sclerosant injection. You may bill separately for the catheter drainage, however, using an appropriate code such as 49406 (Image-guided fluid collection drainage by catheter [e.g., abscess, hematoma, seroma, lymphocele, cyst]; peritoneal or retroperitoneal, percutaneous).