Ask Dr. Z

Question ID 5448 says report code 49406 for trans-gluteal approach. Code 10030 would be for a soft tissue drainage in the buttocks, not in front of the sacrum, which is in the pelvic cavity.

Question ID 8089 says The catheter must be indwelling for 49405, 49406, 49407, and 10030. Indwelling is not just a couple hours. It is intended as a long-term drainage (more than on a single DOS).

If 49405-49407 & 10030 must be indwelling and 10160 is for superficial / subQ drainage and 49083 is for ascites, and 50390 is for a cyst, what would be the appropriate code for when only a needle is used to drain a deep peritoneal fluid collection and no drain is left behind?

Example: US-guided and therapeutic aspiration of intra-peritoneal fluid collection around transplant kidney.

Local anesthesia was administered. .. ultrasound guidance .. 5 Fr Yueh advanced into the fluid collection with spontaneous return of fluid. A total of 65 cc of fluid was removed, a sample submitted for laboratory analysis. Hemostasis was achieved.

Thanks!