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Salivary gland mucocele, drainage & sclerotherapy

Date: Feb 24, 2021

Question:

Dictation reads: "Under ultrasound guidance, 14 gauge Angiocath was advanced into the fluid collection from a left midline approach directed laterally. Approximately 18 mm of dark red serosanguineous fluid was aspirated. This was relatively thin, but became slightly thick towards the end of the aspiration. The entire collection was able to be aspirated from the left-sided Angiocath. Next, sclerotherapy was performed by slowly infusing a total of approximately 13 mL of 98% dehydrated alcohol. This was manually manipulated throughout the entire collection. The catheter was left in place for approximately 30 minutes while continuing to perform ultrasound imaging. The fluid within the cystic collection slowly became irregularly echogenic. The catheter was then removed and a pressure dressing was applied." I coded 49185, but it was returned internally due to no contrast. A senior coder is suggesting 10160/76942. I am concerned we are not capturing the injection of the sclerotherapy. What are your recommendations for facility coding? 

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