Ask Dr. Z

Psoas muscle (abscess) aspiration - what is the CPT code for this procedure? Site muscle unlisted code 20999 or what?   How does this related to the "findings" description? 

INDICATION: Left central and muscle fluid collection r/o abscess. PROCEDURE: Patient placed lateral decubitus on CT gantry couch. After induction of anesthesia, pre-procedure scan performed to select an appropriate entry site. Mark placed on the skin overlying left lower axilla, which was prepped in the usual fashion with wide barrier chlorhexidine preparation. Site then anesthetized with 1% lidocaine. Under fluoroscopic guidance, an 18 gauge trocar needle was inserted from 6 x 4 cm cystic fluid collection in the left psoas muscle. Approximately 52 mL of series fluid was aspirated. Needle withdrawn. Patient tolerated the procedure well without procedural complication. Multiple fluoroscopic spot images confirmed intra-articular location of contrast. FINDINGS: A well-circumscribed cystic fluid collection measuring 6 x 4 cm in the left upper pelvis/left lower quadrant of the abdomen. Impression: 1. Successful and uneventful CT-guided left psoas muscle aspiration. 2. 52 mL of serosanguinous fluid collected and sent for culture analysis and cell count.