Wiki Drainage catheter placement

Good Morning

I have a question regarding an IR procedure, it is a percutaneous placement of a 10 French drainage catheter into a complex anterior abdominal fluid collection. Provider submitted 75989 only, which is guidance only. We are in need of the primary CPT. We are leaning towards 49405 or 49406 alone, however provider is disputing code. I have attached his dictation, thank you all for your help.


Pre-procedure diagnosis: Complex anterior abdominal fluid collection

Complications: No immediate complications.

IMPRESSION:

Percutaneous placement of a 10 French drainage catheter into complex anterior
abdominal fluid collection, yielding fluid

PROCEDURE SUMMARY:
-10 French abdominal drainage catheter placement under sonographic guidance
- Additional procedure(s): None


Drainage catheter placement
The patient was positioned supine. Initial imaging was performed. Local
anesthesia was administered. The fluid collection was accessed using sonographic
guidance and a drainage catheter was placed. Position of the drainage catheter
within the fluid collection was confirmed.
- Initial imaging findings: Anterior abdominal complex fluid collection
- Drainage catheter placed: 10 French skater
- External catheter securement: Adhesive device
- Post-drainage imaging findings: Pigtail within the fluid collection




Additional Details
Additional description of procedure: None
Equipment details: None
Specimens removed: Aspirated fluid sent for analysis.
Estimated blood loss (mL): Less than 10
Standardized report: SIR_DrainPlacement_v3

Remind the provider that imaging is bundled into the drainage procedure.