Wiki Aspirating serosanguineous fluid

[Coder.Melisa]

Insurance claim denied. Was told that the CPT code of 62268 was not adequate. May someone please help with figuring out the corrected code to use for aspirating serosanguineous fluid. Thank you. Any help would be greatly appreciated. Medical record is as follow

"Using fluoroscopy, the right L4-5 neural foramen was identified and the skin above the this region was infiltrated with Xylocaine using a 25-gauge needle. A 22-gauge spinal needle was advanced under fluoroscopic guidance to the neural foramen. The needle was advanced while aspirating a small amount of serosanguineous fluid. A 22-gauge Whitaker needle was advanced under fluoroscopic guidance to the right L5-S1 neural foramen. Proper needle placements were confirmed using multiple fluoroscopic views in the oblique, lateral and AP positions. Proper needle placement were further confirmed by administrations of 1 cc of Isovue M200 contrast material at each level. Appropriate transforaminal epidural spread patterns were identified. There was no vascular uptake."

 

[dwaldman]

62268
Percutaneous aspiration, spinal cord cyst or syrinx

"The physician removes the contents of a cyst or syrinx with a needle. An x-ray verifies placement of the needle (separately reportable). A spinal needle is inserted once the cyst or syrinx is located. The contents of the cyst are aspirated and the needle is removed. The wound is dressed."

62267
Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes

"The physician removes contents within the intervertebral disc, nucleus pulposus, or paravertebral tissue with a needle for diagnostic purposes. Separately reportable computed tomography or fluoroscopic guidance verifies placement of the needle. A spinal needle is inserted, the contents of the targeted location are aspirated, and the needle is removed."

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AMA CPT Changes 2009

"Code 62267 was established to report percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes. This code is intended to report the aspiration of fluid and/or cells of a percutaneous disc, nucleus pulposus, or paravertebral diagnostic purposes. This service is provided to evaluate cervical, thoracic, or lumbar infectious discitis; to evaluate spinal and/or paravertebral fluid accumulations; or to harvest cells for diagnostic or therapeutic purposes"


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CPT 62268 states it is aspiration of spinal cord cyst or syrinx. The procedure note did not describe what the suspected diagnosis was or that it involved aspiration of spinal cord cyst or syrinx. CPT 62267 describes aspiration that could occur in the paravertebral tissue.

Other codes below such as don't seem to come closer to what is trying to be capture. The fact that AMA CPT Changes states that CPT 62267 could be reported for was why I mentioned this code but the specific condition was not mentioned in the initial post.

"to evaluate spinal and/or paravertebral fluid accumulations;"

10160
Puncture aspiration of abscess, hematoma, bulla, or cyst

10022
Fine needle aspiration; with imaging guidance

10030
Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous