Radiology Coding Alert

Question: Which CPT and ICD-9 codes should I report when the radiologist performs a transrectal ultrasound (US), finds a prostatic cyst, and then provides transrectal US guidance for cyst aspiration?


Illinois Subscriber


Answer: For the diagnostic ultrasound, you should report 76872 (Ultrasound, transrectal).

For the needle aspiration of the prostatic cyst, your best bet is 10160 (Puncture aspiration of abscess, hematoma, bulla or cyst).

CPT doesn't offer a specific code for prostate cyst aspiration, but the American College of Radiology (ACR) suggests using 10160 when you don't have a site-specific code available (ACR Coding Source, November/December 2005).

Alternative: ACR says 10022 (Fine needle aspiration; with imaging guidance) is a second coding option if you aspirate fluid "with the purpose of characterization of the fluid collection."

Either code is, therefore, acceptable.

A note with 10160 tells you to look to the following codes to report imaging guidance with this aspiration procedure:

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

• 77012--Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation

• 77021--Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization
device) radiological supervision and interpretation.

A note with 10022 lists the same codes but adds the option of 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]).

According to the documentation, the physician provided US guidance, so you should report 76942.

The diagnosis code that describes the prostatic cyst is 600.3 (Cyst of prostate).