Patient presented with a soft tissue mass on the Left Hallux. Provider decided to try to get a sample from the mass/cyst to submit to pathology. Was unable to aspirate much fluid. Attempting to figure out a procedure code for this service. I am including a portion of the procedure note. Just need to know if this is a service that can be billed and if so, what CPT code to use.
PROCEDURE:
The injection site was marked. Surgical consent form completed and explained. A time out was done to verify the correct patient and injection site. A ring block was administered around the cyst utilizing 1% lidocaine plain. The pericyst region was then prepped in sterile fashion utilizing ChloraPrep and allowed to dry per manufacture recommendation. The bolus prominent portion of the cyst was then identified and an 18 gauge needle with syringe attached was inserted to attempt aspiration. Under 1 cc of aspirate he was able to be collected. The fluid was sent for crystals and culture given the limited volume. The needle was removed. The area was manually compressed along the course of the cyst expelling approximately 1mL of serosanguineous fluid through needle tract. The mass was found to be largely dense tissue. Therefore no corticosteroid was administered given the thinned skin coverage. Hemostasis was achieved with light compression. Topical bacitracin was applied. A gauze dressing was a applied over the procedure site. Patient tolerated injection well.
Thank you for reviewing this.
PROCEDURE:
The injection site was marked. Surgical consent form completed and explained. A time out was done to verify the correct patient and injection site. A ring block was administered around the cyst utilizing 1% lidocaine plain. The pericyst region was then prepped in sterile fashion utilizing ChloraPrep and allowed to dry per manufacture recommendation. The bolus prominent portion of the cyst was then identified and an 18 gauge needle with syringe attached was inserted to attempt aspiration. Under 1 cc of aspirate he was able to be collected. The fluid was sent for crystals and culture given the limited volume. The needle was removed. The area was manually compressed along the course of the cyst expelling approximately 1mL of serosanguineous fluid through needle tract. The mass was found to be largely dense tissue. Therefore no corticosteroid was administered given the thinned skin coverage. Hemostasis was achieved with light compression. Topical bacitracin was applied. A gauze dressing was a applied over the procedure site. Patient tolerated injection well.
Thank you for reviewing this.