Ask Dr. Z

"Patient has a cystic pelvic mass that needs frequent draining, and drain is already in place. When patient comes to the radiology suite, contrast is injected under fluoro, and multiple images are taken and stored in PACS. The cystic mass is completely drained by approximately 470 mL of yellow fluid via the existing drain, then 35 mL of Betadine was injected through the drain tube to perform sclerosis. The tube was capped for one hour, then the Betadine was drained. The drain was left in place." In addition to the 49185 sclerotherapy procedure, are we able to code for the drainage procedure that proceeded the sclerotherapy since the drain was already in place and a new drain was not placed? Can we report codes 49406 and 49185-59, or should we only report code 49185 for this scenario with the drainage procedure being included?