The complexity of interventional radiology is only increasing, with coding errors posing a constant threat to your bottom line. Not only do facilities risk being paid less or having reimbursement slashed through denials, but it also puts compliance at risk, leading to potential audits. Drainage procedures are an especially difficult area, identified by our nationally renowned subject matter experts as one requiring review. Case studies remain a time-tested approach, offering valuable insights into coding scenarios that reinforce accuracy and comprehensive understanding. This month, we explore three drainage-related case studies to break down barriers and ensure foolproof success in 2024 and beyond.
CASE 1: FLUOROSCOPIC AND ULTRASOUND-GUIDED PLACEMENT OF A SUPRAPUBIC
CATHETER (14-FRENCH PIGTAIL)
History: Urinary retention. Suprapubic catheter is now requested. Informed consent was obtained from the patient’s daughter. The patient was brought to the angio suite and placed in a supine position. The existing Foley catheter was injected with a dilute contrast saline solution for bladder distention.
The urinary bladder was identified under ultrasound.
In the midline or just to the right of midline and just above the pubic bone, an 18-gauge single-wall needle was advanced into the urinary bladder. A Rosen wire was then coiled within the urinary bladder.
Following fascial dilatation, a 14-French Flexima locking pigtail drainage catheter was then advanced and positioned within the bladder. The pigtail was formed and locked and secured to the skin with 2-0 Ethilon suture. Both the pigtail catheter and the Foley catheter were then connected to external bag drainage. The patient tolerated the procedure well without complication.
Findings:
1. Urinary bladder is identified under ultrasound with Foley catheter indwelling. There is prostate
enlargement.
2. Successful fluoroscopic and ultrasound-guided placement of a 14-French pigtail catheter
within the urinary bladder utilized as a suprapubic cystostomy tube.
| 51102 | Aspiration of bladder; with insertion of suprapubic catheter |
| 76942 | Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation |
A catheter was placed into the bladder through a percutaneous approach and left in place for longer term drainage. If the catheter had been removed at the end of the session, code 51101 would have been assigned instead of 51102.
Written informed consent was obtained. Preliminary scanning was performed over the posterior left hemithorax. This demonstrated a moderate-sized left pleural effusion. After choosing an appropriate location, this area was sterilely prepped and draped. Local anesthesia was provided with buffered lidocaine solution. Then using ultrasound guidance, a 5 French multi-side-hole catheter was advanced into the left pleural space. Pleural fluid was easily obtained. Approximately 60 cc were sent to the laboratory for further analysis. Subsequently, an additional 900 cc of pleural fluid were removed.
A total of 960 cc was removed in total. The catheter was removed, and there were no immediate complications
Impression: Ultrasound guided left-sided thoracentesis as described.
| 32555 | Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance |
Since the catheter was removed at the end of the session, code 32555 for thoracentesis would be assigned instead of 32557. Ultrasound guidance is included, so do not also code 76942.
Indication: Diverticular abscesses.
Discussion: The patient was referred for abscess drainage with CT guidance; outside imaging had shown multiple fluid collections in the pelvis. The patient was reimaged at the time of the procedure with abundant oral contrast opacifying the colon. There are at least 2 apparently separate fluid collections and possibly a plaque of communication with a posterior portion of the fluid collection on the left. The fluid collections are amenable to anterior access, the posterior aspect of the fluid collection on the left is shielded by pelvic bone and internal iliac artery and neurovascular bundle. These findings were discussed with the patient’s primary doctor prior to the procedure, and it was determined that an attempt at percutaneous drainage would be made, and if this was either unsuccessful or incompletely resolves the fluid collections, then surgery may be considered. This was discussed with the patient and her daughter, and they agreed to proceed.
The patient was placed on the CT gantry in a supine position, the fluid collections were localized, and a skin entry site was chosen in each lower quadrant. The sites were marked, the areas were prepped and draped sterilely and local anesthesia was provided with 2% lidocaine. At each site a separate Accu-Stik needle was utilized to puncture the abscess cavities following provision of local anesthesia with 2% lidocaine. A wire was placed, the tract was dilated with a fascial dilator, and an 8-French locking pigtail multi-side-hole drainage catheter was placed over the wire into each of the cavities. A total of approximately 25 mL of purulent fluid was removed from each cavity, labeled separately, and sent to the laboratory for culture and sensitivity. Each catheter was placed to dependent drainage. The catheters were sutured to the skin surface with a single stitch each.
The patient tolerated the procedure well. Conscious sedation was utilized during the exam.
Impressions:
1. Percutaneous CT-guided abscess drainage for two pelvic abscesses, two separate catheters
placed. No immediate complication.
2. Recommend interval followup with repeat CT scan in the next 2 to 5 days for re-evaluation
of these fluid collections and to determine whether the posterior aspect of the left-side fluid
collection is draining adequately.
3. Conscious sedation utilized during the exam.
| 49406 | x 2 Image-guided fluid collection drainage by catheter (e.g., abscess, hematoma, seroma, |
lymphocele, cyst); peritoneal or retroperitoneal, percutaneous Two separate abscess collections were treated, each with a separate catheter placement. The report documents that the catheters were sutured to the skin, indicating that they were left in place. Guidance is included in 49406, so 77012 would not be separately coded. Modify or bill with units as directed by the individual payer.
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