Wiki 49407 or 10160, 76942

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Would you bill 49407 or 10160,76942? THANKS!

Ultrasound and fluoroscopic-guided transvaginal pelvic aspiration

History: Status post hysterectomy and bilateral salpingo-oophorectomy. Most recent surgery about 6 weeks ago. Pelvic fluid collection with pain. Low-grade fever.

Technique: Timeout performed. Patient placed in left lateral decubitus position on the fluoroscopy table. Transvaginal probe was placed and under ultrasound guidance, ill-defined mobile fluid collection was identified; 2% lidocaine used as local anesthetic. Moderate sedation also administered. Under combination of ultrasound and fluoroscopy, 5-French ring biliary catheter advanced into the fluid collection and 3 cc of purulent material aspirated. Catheter was removed. No complications occurred.

Findings: There is a complex poorly defined, compressible and mobile fluid collection in the pelvis, demonstrated with the patient in the left lateral decubitus position. A discrete abscess is not demonstrated. Purulent material was aspirated. The collection was not clearly defined or amenable to drainage due to its size and mobility. Fluid analysis is pending.


Result Impression


Successful and uncomplicated transvaginal pelvic aspiration.
 
I would go with 49407, Because of the Cath that was placed.




From TruCode (Encoder Software)




49407-Imaging is performed to assist in the insertion of a needle or guidewire into the fluid collection. Small tissue samples may be collected from the site for pathological examination. A catheter is inserted to drain and collect the fluid for analysis and is then removed. In some cases, the catheter may be attached to a bag to allow for further drainage over the course of days.




10160-The palpable collection of fluid is located subcutaneously. The physician cleanses the overlying skin and introduces a large bore needle on a syringe into the fluid space. The fluid is aspirated into the syringe, decompressing the fluid space. A pressure dressing may be placed over the site.
 
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