Tuesday, January 18, 2022

Surgery: Integumentary System, 10160, 76942 (Q&A)

 CPT Assistant, August 2021, Volume 31, Issue 8, page 14

Question:

What Current Procedural Terminology (CPT®) code should be reported for aspiration of postoperative breast seroma with ultrasound guidance, when performed outside the assigned global period of the previous breast procedure? Under direct sonographic guidance, an 18-gauge spinal needle was inserted into the breast. Subsequent aspiration of approximately 25 mL of serosanguineous fluid was performed and complete collapse of the seroma was achieved.

Answer:

In the scenario presented, it would be appropriate to report codes 10160, Puncture aspiration of abscess, hematoma, bulla, or cyst, for the seroma aspiration and 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation, for the imaging guidance. However, if the seroma is aspirated in the office during the assigned global period of the breast procedure, it would not be separately reportable.

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