Q & A with Dr. Z: Sclerotherapy without Imaging Guidance, Diagnostic Study, Contrast

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC

Can we use CPT code 49185 if imaging guidance wasn’t performed and contrast wasn’t administered? Can we also use CPT code 49185 when sclerosants aren’t used?

Per documentation, provider Injected 30 mL of desiccated ethanol into the abdominal wall seroma via previously placed drain. Patient was turned every 15 minutes to allow the alcohol to bathe all sides of the seroma cavity. The alcohol was then aspirated completely with 30 mL removed. Patient tolerated procedure well.

Yes, CPT code 49185 would be used here. Usually an ablation of a cystic structure is performed with alcohol, as described here. The placement of the catheter (such as 49405 or 49406) would also be reported if done at the same session (which bundles imaging guidance).


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About the Author

David Zielske is founder and President of ZHealth Publishing and primary author and editor of ZHealth publications. Dr. Z practiced as an interventional radiologist and has over twenty years experience as a coding reviewer and coding expert. He is Board Certified in Radiology and has functioned as an independent interventional radiology, vascular surgery, and cardiovascular coding consultant to a variety of physician groups and hospital providers across the country. He also served as an instructor for over 200 coding seminars.

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