Q Which code should I report for a computed tomography (CT)-guided drainage of an ovarian cyst via a vaginal approach?
A You actually need to list 2 codes for this procedure. For the drainage of the cyst, report 58800 (vaginal approach). To bill for the CT guidance, report code 76003 (fluoroscopic guidance for needle placement, e.g., biopsy, aspiration, injection; localization device). This code is the best option because it most closely reflects the type of guidance used. (Fluoroscopic CT guidance is rapidly becoming the procedure of choice because it provides the physician with a continuous image of the needle’s position, whereas conventional CT guidance takes 1 picture at a time.)
This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.