How To Use CPT Code 19000

CPT code 19000 describes the procedure of puncture aspiration of a cyst in the breast. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 19000?

CPT 19000 is used to describe the procedure of puncture aspiration of a cyst in the breast. This involves the insertion of a sterile needle into the cyst to drain out the fluid. The procedure is typically performed under local anesthesia, and the provider may use imaging guidance, such as ultrasound or magnetic resonance imaging (MRI), to assist in locating and accessing the cyst.

2. Official Description

The official description of CPT code 19000 is: ‘Puncture aspiration of cyst of breast.’

3. Procedure

During the procedure, the patient is appropriately prepped and anesthetized, usually with local anesthesia. The provider then inserts a sterile needle into the cyst, guided by imaging if necessary. The fluid is withdrawn from the cyst, relieving any discomfort or pressure caused by its presence. The provider ensures hemostasis, or stoppage of bleeding, and applies pressure to the site to prevent the accumulation of blood outside the blood vessels.

4. Qualifying circumstances

CPT 19000 is performed on patients with breast cysts that require drainage. A breast cyst is a closed capsule-like structure filled with fluid. The procedure is typically performed by a qualified healthcare professional, such as a physician or nurse, who has the necessary training and expertise to safely perform the aspiration.

5. When to use CPT code 19000

CPT code 19000 should be used when a provider performs a puncture aspiration of a breast cyst. This code is appropriate when the procedure is performed on an individual patient. If multiple cysts are aspirated during the same session, use the additional code 19001 for each additional cyst.

6. Documentation requirements

To support a claim for CPT 19000, the provider must document the following information:

• Patient’s diagnosis indicating the presence of a breast cyst
• Procedure performed, including the use of imaging guidance if applicable
• Date and time of the procedure
• Details of the aspiration, including the amount of fluid withdrawn
• Any complications or additional procedures performed
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 19000, ensure that the procedure meets the criteria for puncture aspiration of a breast cyst. If the procedure is performed under imaging guidance, such as ultrasound or MRI, report the appropriate imaging code (e.g., 76942 for ultrasound or 77021 for MRI) in addition to CPT 19000. If multiple cysts are aspirated during the same session, use the additional code 19001 for each additional cyst.

8. Historical information

CPT 19000 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates or changes since its addition.

9. Similar codes to CPT 19000

There are several similar codes to CPT 19000 that describe procedures related to breast cysts and aspirations. These include:

• CPT 19001: Aspiration of each additional cyst of the breast, reported in addition to CPT 19000
• CPT 76942: Ultrasound guidance for needle placement, reported in addition to CPT 19000 when ultrasound is used for guidance
• CPT 77021: Magnetic resonance guidance for needle placement, reported in addition to CPT 19000 when MRI is used for guidance

9. Examples

1. A physician performing a puncture aspiration of a breast cyst for a patient with a known diagnosis of a cyst.
2. A radiologist using ultrasound guidance to perform a puncture aspiration of a breast cyst for a patient with a complex cyst.
3. A surgeon performing a puncture aspiration of multiple breast cysts during the same session, using CPT 19000 for the first cyst and CPT 19001 for each additional cyst.
4. A nurse practitioner performing a puncture aspiration of a breast cyst under the supervision of a physician.
5. A radiologist using MRI guidance to perform a puncture aspiration of a breast cyst for a patient with a history of difficult-to-locate cysts.
6. A surgeon performing a puncture aspiration of a breast cyst for a patient with a family history of breast cysts.
7. A physician performing a puncture aspiration of a breast cyst for a patient with symptoms of pain and discomfort.
8. A radiologist using ultrasound guidance to perform a puncture aspiration of a breast cyst for a patient with a suspicious cyst on imaging.
9. A surgeon performing a puncture aspiration of a breast cyst for a patient undergoing a breast biopsy procedure.
10. A nurse practitioner performing a puncture aspiration of a breast cyst for a patient with a known history of recurrent cysts.