How To Use CPT Code 49083

CPT 49083 refers to an abdominal paracentesis procedure with imaging guidance, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 49083?

CPT 49083 is a medical procedure code used to describe an abdominal paracentesis with imaging guidance. This procedure involves the withdrawal of an abnormal buildup of fluid from the abdominal cavity for diagnostic or therapeutic purposes, using imaging guidance to ensure accurate needle placement and fluid drainage.

2. 49083 CPT code description

The official description of CPT code 49083 is: “Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance.”

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. An incision is made in the abdomen.
3. With the aid of imaging guidance, a needle is inserted through the incision.
4. A catheter is inserted along with the needle.
5. The needle is removed, leaving the catheter in place for fluid drainage.
6. Fluid is drained from the abdomen through the catheter.
7. The catheter is removed, and the provider checks for bleeding.
8. The incision is closed.

4. Qualifying circumstances

Patients eligible to receive CPT code 49083 services are those experiencing an abnormal buildup of fluid in the abdominal cavity, causing pressure, pain, or other complications. This fluid accumulation may be due to various medical conditions, such as liver disease, heart failure, or cancer. The procedure may be performed for diagnostic purposes, to obtain a fluid sample for laboratory analysis, or for therapeutic purposes, to relieve pressure and pain caused by the fluid buildup.

5. When to use CPT code 49083

It is appropriate to bill the 49083 CPT code when a provider performs an abdominal paracentesis with imaging guidance for diagnostic or therapeutic purposes. The use of imaging guidance, such as ultrasound or computed tomography (CT), helps ensure accurate needle placement and minimizes the risk of complications during the procedure.

6. Documentation requirements

To support a claim for CPT 49083, the following information should be documented in the patient’s medical record:

• Indication for the procedure, including the patient’s symptoms and relevant medical history.
• Type of imaging guidance used during the procedure.
• Details of the procedure, including the site of the incision, needle and catheter insertion, and fluid drainage.
• Any complications encountered during the procedure and their management.
• Results of any laboratory analysis performed on the fluid sample, if applicable.
• Post-procedure care instructions and follow-up plan.

7. Billing guidelines

When billing for CPT code 49083, it is essential to follow the appropriate guidelines and rules to ensure accurate reimbursement. Some tips and codes that apply to CPT code 49083 include:

• Do not report CPT 49083 in conjunction with 76942, 77002, 77012, or 77021.
• For percutaneous image-guided drainage of retroperitoneal abscess by catheter, use CPT code 49406.
• For the same service without imaging guidance, use CPT code 49082.

8. Historical information

CPT 49083 was added to the Current Procedural Terminology system on January 1, 2012. There have been no updates to the code since its addition.

9. Similar codes to CPT 49083

Five similar codes to CPT 49083 and how they differ are:

• CPT 49082: Abdominal paracentesis without imaging guidance, used when the procedure is performed without the aid of imaging technology.
• CPT 49406: Percutaneous image-guided drainage of retroperitoneal abscess by catheter, used for draining an abscess in the retroperitoneal space rather than fluid from the abdominal cavity.
• CPT 76942: Ultrasonic guidance for needle placement, used when ultrasound guidance is provided for a different procedure, not abdominal paracentesis.
• CPT 77002: Fluoroscopic guidance for needle placement, used when fluoroscopic guidance is provided for a different procedure, not abdominal paracentesis.
• CPT 77012: Computed tomography guidance for needle placement, used when CT guidance is provided for a different procedure, not abdominal paracentesis.

10. Examples

1. A patient with liver cirrhosis experiencing abdominal pain and distension undergoes CPT 49083 to relieve pressure and pain caused by fluid buildup.
2. A patient with heart failure and worsening shortness of breath undergoes CPT 49083 to drain excess fluid from the abdominal cavity.
3. A patient with suspected peritoneal carcinomatosis undergoes CPT 49083 to obtain a fluid sample for laboratory analysis.
4. A patient with a history of abdominal surgeries and recurrent ascites undergoes CPT 49083 for therapeutic drainage of fluid.
5. A patient with end-stage renal disease on peritoneal dialysis undergoes CPT 49083 to drain excess fluid due to inadequate dialysis clearance.
6. A patient with pancreatic cancer and ascites undergoes CPT 49083 to alleviate discomfort and improve quality of life.
7. A patient with a history of alcohol abuse and liver cirrhosis undergoes CPT 49083 to diagnose spontaneous bacterial peritonitis.
8. A patient with ovarian cancer and ascites undergoes CPT 49083 to relieve pressure on surrounding organs and improve respiratory function.
9. A patient with congestive heart failure and refractory ascites undergoes CPT 49083 to manage fluid overload and improve symptoms.
10. A patient with a history of tuberculosis and suspected tuberculous peritonitis undergoes CPT 49083 to obtain a fluid sample for laboratory analysis.