Ask Dr. Z

LESION/LOCATION: Right 10:00-11:00, 5-8 cm from the nipple. TECHNIQUE: Ultrasound-guided needle aspiration. The skin was prepped in the usual fashion. 5 cc of 1% buffered lidocaine was used for local anesthesia in the skin and deeper tissues using ultrasound guidance. Preliminary ultrasound shows multiple benign cysts in the right upper outer quadrant. Using a single entry site, 5 of the benign cysts in the right upper outer quadrant were aspirated using an 18-gauge needle and ultrasound guidance, yielding a total of 7 cc of tan fluid. Aspirated cyst were seen to completely resolve on real-time ultrasound. The patient tolerated the procedure well and there were no complications." Do you recommend coding this as CPT 19000, 19001 x 4, 76942... or 19000, 76942? For CPT 19001, does it have to be a separate needle puncture into each cyst, or can it be one needle puncture and redirect the needle to adjacent cysts to drain each one?