How To Use CPT Code 33016

CPT 33016 describes the procedure of pericardiocentesis, which involves draining fluid from the pericardial space using a needle inserted through the chest wall. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 33016?

CPT 33016 is a code that represents the pericardiocentesis procedure. It involves the insertion of a needle through the chest wall into the pericardial space to drain fluid. This procedure is typically performed to relieve pericardial effusion or cardiac tamponade, as well as for diagnostic, palliative, or prophylactic purposes.

2. Official Description

The official description of CPT code 33016 is: ‘Pericardiocentesis, including imaging guidance, when performed.’

3. Procedure

1. The provider selects a site between the xiphoid process and the left sternocostal margin.
2. A small incision may be made to reduce needle resistance.
3. The provider advances a needle attached to a syringe or suction device into the pericardial space.
4. Imaging guidance, such as fluoroscopy or ultrasound, may be used to ensure accurate needle placement.
5. The provider aspirates fluid from the pericardial sac into the syringe.
6. The needle is then withdrawn.

4. Qualifying circumstances

Pericardiocentesis may be performed for various reasons, including relieving pericardial effusion or cardiac tamponade, as well as for diagnostic, palliative, or prophylactic purposes. It is important to note that CPT code 33016 should not be reported in conjunction with codes 76942, 77002, 77012, or 77021.

5. When to use CPT code 33016

CPT code 33016 should be used when performing pericardiocentesis, which involves draining fluid from the pericardial space. It is important to ensure that the procedure includes imaging guidance, as this is included in the code description. This code should not be reported with certain other codes, as mentioned above.

6. Documentation requirements

To support a claim for CPT code 33016, the provider must document the following information:

• Reason for performing pericardiocentesis
• Details of the procedure, including the site of needle insertion and any incisions made
• Use of imaging guidance, if performed
• Amount of fluid aspirated from the pericardial sac
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 33016, it is important to ensure that the procedure includes imaging guidance, as this is included in the code description. This code should not be reported with codes 76942, 77002, 77012, or 77021. It is also important to follow any specific guidelines provided by payers regarding documentation and billing for this procedure.

8. Historical information

CPT code 33016 was added to the Current Procedural Terminology system on January 1, 2020. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoes pericardiocentesis to relieve pericardial effusion.
2. Pericardiocentesis is performed as a diagnostic procedure to determine the cause of symptoms.
3. A patient with cardiac tamponade undergoes pericardiocentesis as an emergency procedure.
4. Pericardiocentesis is performed as a palliative procedure to provide relief from symptoms.
5. A patient with a history of pericardial effusion undergoes prophylactic pericardiocentesis to prevent recurrence.
6. Pericardiocentesis is performed under imaging guidance to ensure accurate needle placement.
7. A patient with a congenital cardiac anomaly undergoes pericardiocentesis to relieve pericardial effusion.
8. Pericardiocentesis is performed as a diagnostic procedure to rule out pericardial effusion in a patient with chest pain.
9. A patient with a large pericardial effusion undergoes pericardiocentesis to improve cardiac function.
10. Pericardiocentesis is performed as a palliative procedure to provide relief from symptoms in a patient with advanced cancer.