Revenue Cycle Insider

Question: A patient presented with a soft tissue mass on the left hallux. The provider decided to try to get a sample from the mass/cyst to submit to pathology. They were unable to aspirate much fluid. I’m attempting to figure out a procedure code for this service. Below is a portion of the procedure note.

Procedure: A ring block was administered around the cyst utilizing 1 percent lidocaine plain. The pericyst region was then prepped in sterile fashion utilizing ChloraPrep and allowed to dry per manufacture recommendation. The bolus prominent portion of the cyst was then identified and an 18-gauge needle with syringe attached was inserted to attempt aspiration. Under 1 cc of aspirate was able to be collected. The fluid was sent for crystals and culture given the limited volume. The needle was removed. The area was manually compressed along the course of the cyst expelling approximately 1 mL of serosanguineous fluid through needle tract. The mass was found to be largely dense tissue.

What procedure code should I use?

Colorado Subscriber

Answer: Based on what you’ve provided in the procedure note sample, it appears that the physician performed an aspiration of a cyst on the patient’s left hallux. You’ll assign 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst) to report this procedure. This code covers aspiration regardless of whether fluid or other material was collected. Code 10160 also covers the use of local anesthesia and dressing application.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC