Cpt code 10160 or 10030?

Messages
13
Best answers
0
I need a second set of eyes to look at this one - and if you could explain why it is one or the other that would be great. Thank you - would it be 10030 or 10160?

EXAM: US SUPERFICIAL / PUNC FLUID DRAIN

CLINICAL INFORMATION: 76-YEAR-OLD FEMALE WITH HISTORY OF LEFT BREAST
LUMPECTOMY WITH RECURRENT POSTOPERATIVE SEROMA, PLEASE PERFORM
ULTRASOUND-GUIDED ASPIRATION.

COMPARISON: 12/28/2018 AND 12/10/2018

FINDINGS:
INFORMED VERBAL AND WRITTEN CONSENT WAS OBTAINED FROM THE PATIENT. THE
PATIENT`S QUESTION FOR CANCER. THE PATIENT APPEARED UNDERSTAND AND
WISHED TO PROCEED. A TIMEOUT WAS PERFORMED UNDER MY SUPERVISION.
INITIAL SONOGRAPHIC EVALUATION CONFIRMED AN ANECHOIC LEFT BREAST FLUID
COLLECTION MEASURING 6 X 6.1 X 2.7 CM, COMPATIBLE WITH THE PATIENT`S
RECURRENT LEFT BREAST SEROMA. THE LEFT BREAST WAS PREPPED IN USUAL
STERILE FASHION. LOCAL ANESTHESIA WAS OBTAINED WITH 1% LIDOCAINE. A
YUEH CENTESIS CATHETER WAS ADVANCED DIRECTLY INTO THE SEROMA. A TOTAL
OF 52 ML OF GOLDEN FLUID WAS ASPIRATED AND SENT TO THE LABORATORY FOR
FURTHER ANALYSIS. NO RESIDUAL FLUID WAS SEEN POST ASPIRATION. THE
PATIENT TOLERATED THE PROCEDURE WELL.

IMPRESSION:

1. ULTRASOUND-GUIDED ASPIRATION OF A RECURRENT LEFT BREAST SEROMA, AS
DETAILED ABOVE.
2. A TOTAL OF 52 ML OF GOLDEN FLUID WAS ASPIRATED AND SENT TO THE
LABORATORY. NO RESIDUAL FLUID COLLECTION WAS SEEN POST ASPIRATION.
FINAL READING DR.: KIM, KYU
THIS REPORT HAS BEEN ELECTRONICALLY SIGNED BY: KIM, KYU
 

SWheeldon

New
Messages
5
Best answers
0
The documentation supports 10160 and 76942. 10030 is used then the catheter is left in place for further drainage, which this report states no residual fluid seen post aspiration, and would not apply.
 
Top