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drainage

  1. Default drainage
    Medical Coding Books
    This should be coded as 49021 & 75989 or 50390 & 76942.

    84 year old male with large left renal cyst resulting in
    significant abdominal distension (difficulty with wearing clothes)
    referred for percutaneous drainage.

    Indication: abdominal distension

    Procedure:
    With the patient in the supine position the left mid abdomen was
    prepped and draped in the usual sterile fashion. Ultrasound
    examination demonstrates a well-circumscribed fluid collection
    correlating well with the findings on CT.There is a smooth margins
    to the cyst wall. Multiple, thin sepations are present in the
    more dependent portions of the cyst.
    After administration of local anesthesia, access was obtained
    into the fluid cavity using an 18 gauge needle under real time
    ultrasound guidance. Several cc's of chocolate colored fluid were
    aspirated and sent for microbiology and chemistry. Exchange was
    made for serial dilators under fluoroscopic guidance after which
    an 8 French pigtail drainage catheter was placed successfully in
    the cavity using fluoroscopic guidance. Approximately 2700 cc's
    of fluid were aspirated.

    Subsequently 30 cc of anhydrous absolute alcohol was instilled
    into the cyst cavity. The catheter was capped. The patient was
    placed in different positions on the stretcher to insure coating
    of the lining of the cyst with the sclerosing agent. After 25
    minutes, residual alcohol was aspirated and the catheter was
    removed. The patient tolerated the procedure without incident.

    Conclusion:
    Real time ultrasound-guided access of a large left renal cyst.

    Multiple internal septations within the cyst cavity are
    demonstrated on ultrasound exam. No definitive mural nodules are
    identified.

    Ultrasound guided aspiration and drainage of a large left renal
    cyst with drainage of 2700 cc of chocolate colored fluid.

    Sclerosis of large left renal cyst using anhydrous absolute
    ethanol as described above.
    Prabha CPC

  2. #2
    Default
    CPT codes should be 50390 & 76942.

  3. #3
    Default
    Quote Originally Posted by prabha View Post
    This should be coded as 49021 & 75989 or 50390 & 76942.

    84 year old male with large left renal cyst resulting in
    significant abdominal distension (difficulty with wearing clothes)
    referred for percutaneous drainage.

    Indication: abdominal distension

    Procedure:
    With the patient in the supine position the left mid abdomen was
    prepped and draped in the usual sterile fashion. Ultrasound
    examination demonstrates a well-circumscribed fluid collection
    correlating well with the findings on CT.There is a smooth margins
    to the cyst wall. Multiple, thin sepations are present in the
    more dependent portions of the cyst.
    After administration of local anesthesia, access was obtained
    into the fluid cavity using an 18 gauge needle under real time
    ultrasound guidance. Several cc's of chocolate colored fluid were
    aspirated and sent for microbiology and chemistry. Exchange was
    made for serial dilators under fluoroscopic guidance after which
    an 8 French pigtail drainage catheter was placed successfully in
    the cavity using fluoroscopic guidance. Approximately 2700 cc's
    of fluid were aspirated.

    Subsequently 30 cc of anhydrous absolute alcohol was instilled
    into the cyst cavity. The catheter was capped. The patient was
    placed in different positions on the stretcher to insure coating
    of the lining of the cyst with the sclerosing agent. After 25
    minutes, residual alcohol was aspirated and the catheter was
    removed. The patient tolerated the procedure without incident.

    Conclusion:
    Real time ultrasound-guided access of a large left renal cyst.

    Multiple internal septations within the cyst cavity are
    demonstrated on ultrasound exam. No definitive mural nodules are
    identified.

    Ultrasound guided aspiration and drainage of a large left renal
    cyst with drainage of 2700 cc of chocolate colored fluid.

    Sclerosis of large left renal cyst using anhydrous absolute
    ethanol as described above.
    I agree with 50390 and 76942, but for the sclerosing procedure, I think you can use the unlisted procedure code, with using the biliary sclerosing charge 47399 as the basis for the cost of procedure.

    Thanks,
    Jim

  4. #4
    Default
    renal cyst sclerose-53899

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