August 31, 2012

ACR Radiology Coding Source™ for July-August 2012 Q and A

Q: A patient was seen for sclerotherapy treatment of a recalcitrant lymphocele. A sclerosing agent of 95 percent ethyl alcohol was used. How should this be reported? Does the coding change based upon the sclerosing agent used?

A: The appropriate codes to report sclerotherapy of nonvascular structures, such as a lymphocele, are 20500, Injection of sinus tract; therapeutic (separate procedure), and 76080, Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation. The ACR and Society of Interventional Radiology agree that these CPT codes should be reported for all non-vascular sclerosis procedures (e.g., seroma, cyst, lymphocele, abscess) and that the use of different agents (e.g., alcohol, tetracycline, betadine) does not limit or alter the reporting of these codes. 
If the patient is being seen for new or worsening symptoms and evaluation and management services are provided by the interventionalist to evaluate those symptoms, evaluation and management (E&M) services should be separately documented and coded. This E&M service may need to be reported with the use of an appropriate modifier (e.g., 24, 25) as the patient’s recent operative history demands. 
Moderate (conscious) sedation is not included in the 20500 code, therefore, it also may be reported separately when performed (e.g., 99144, 99145)