Oncology & Hematology Coding Alert

Question: In a patient suspected to have ovarian tumor, our physician obtained a sample of the fluid from the ovarian cyst under ultrasound guidance. How should we report this procedure?

Florida Subscriber

Answer: You will need to confirm the method used to collect the cystic sample (drainage or fine needle aspiration).   

If the method to obtain the sample required incision and drainage, you have the following two codes to choose from, depending on the approach: 

• 58800, Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach
• 58805, Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach

You should report the radiologic component for guidance with:

• 75989, Radiological guidance (i.e., fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (e.g., abscess, specimen collection), with placement of catheter, radiological supervision and interpretation

If the method to obtain the sample was a fine needle aspiration (FNA), the following codes would be more appropriate: 

• 10022, Fine needle aspiration; with imaging guidance

And, you would report the radiologic component for guidance of the FNA with:

• 76942, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

In both cases, the radiologic supervision and interpretation codes require documentation of imaging type performed, visualization of needle placement, and interpretation of the images.  

If the procedure was performed in another manner, these codes may not be appropriate. Consult with the physician who performed the procedure. Verify the method and specifics to report the correct CPT® codes for the services rendered.