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Radiology Coding Alert

READER QUESTIONS:

Assign 10022, 76360 for This Aspiration

Published on Mon Jan 02, 2006

Question: Which CPT Codes should I use for the following report?

A 22-gauge 20-cm Chiba needle was advanced under CT guidance into the left renal lesion. Repeated aspiration attempts and repositioning of the needle within the lesion produced only a small amount of aspirated sanguineous fluid, about 0.8 ml. Following repeated attempts to aspirate from the lesion with limited success, the needle was removed and superficial pressure held at the percutaneous entrance site for five minutes.


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Answer: The appropriate codes for this procedure are 10022 (Fine needle aspiration; with imaging guidance) and 76360 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation).

Caution: Although the report mentions a percutaneous entrance site, the physician documents an aspiration, so choose 10022 rather than 49180 (Biopsy, abdominal or retroperitoneal mass, percutaneous needle). The answers for You Be the Coder and Reader Questions were reviewed by Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga.; and Gary S. Dorfman, MD, FACR, FSIR.
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