Soft tissue aspiration

oskolkoff

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I need some help coding this procedure. Any suggestions??

A pt comes into the clinic with a swollen let arm. The swelling has increase since she was seen two days ago (x-ray were negative and pt was given spiint to wear). Patient has diffuse pain with palpation around radioscaphoid joint. Patient jumps when area is palpated. There is no pain produced over distal ulna. There is no erythema or ecchymosis. Patient appears to be without pain while sitting. Temperature, sense of touch, capillary refill of affected hand is the same as unaffected hand. There are no paresthesias.

Applied instant topical anesthetic over area of effusion and using clean technique and 18 ga needle, aspirated edematous area which yielded no fluid. Patient tolerated procedure well. This procedure was done in the doctor's office.

What cpt code for the "aspiration"?

Thanks for the help, Jennifer
 

oskolkoff

Networker
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Ninilchik, AK
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CPt 10160

I looked at that cpt code. The arm is swollen. There is no abscess, hematoma, bulla, or cyst. Would cpt 10160 still work?
Thanks, Jennifer
 

CodingKing

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Did they think there might be something there but the came up empty? If so you can still bill for it.
 
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