How To Use CPT Code 48510

CPT 48510 describes the procedure of external drainage for a pancreatic pseudocyst using an open incision. 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 48510?

CPT 48510 can be used to describe the procedure of external drainage for a pancreatic pseudocyst. This code is used when a provider makes an incision above the site of the pseudocyst, dissects down to the pancreas, opens the pseudocyst, drains its contents, and may place a drain for continued drainage. The provider ensures hemostasis and closes the abdominal wound in layers.

2. Official Description

The official description of CPT code 48510 is: ‘External drainage, pseudocyst of pancreas, open.’ This code is used when the provider performs an open incision to reach and drain a pancreatic pseudocyst.

3. Procedure

1. When performing CPT 48510, the provider begins by making an incision above the site of the pseudocyst.
2. Next, the provider dissects down to the pancreas to locate the pseudocyst.
3. Once the pseudocyst is identified, the provider opens it using a puncture incision.
4. The provider then drains all the material in the cyst out of the body.
5. If necessary, the provider may place a drain for continued drainage.
6. After ensuring hemostasis, the provider closes the abdominal wound in layers.

4. Qualifying circumstances

CPT 48510 is performed when a patient has a pancreatic pseudocyst that requires external drainage. A pancreatic pseudocyst is a structure similar to a cyst, usually resulting from pancreatitis, which is inflammation of the pancreas. The procedure is performed by a provider who is appropriately trained and qualified to perform the external drainage using an open incision.

5. When to use CPT code 48510

CPT code 48510 should be used when a provider performs the procedure of external drainage for a pancreatic pseudocyst using an open incision. This code should not be used for percutaneous image-guided fluid collection drainage by catheter of a pancreatic pseudocyst, which is described by CPT code 49405.

6. Documentation requirements

To support a claim for CPT 48510, the provider must document the following information:

• Patient’s diagnosis of a pancreatic pseudocyst
• Description of the procedure performed, including the incision site and technique
• Details of the drainage process, including any additional procedures performed, such as drain placement
• Confirmation of hemostasis and closure of the abdominal wound
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 48510, ensure that the procedure is performed by a qualified provider using an open incision for external drainage of a pancreatic pseudocyst. This code should not be reported with CPT codes 98966 to 98968 if those services have already been performed in the previous seven days. It is important to consider the location of the testing when coding for pulmonary function tests (PFTs) as they have both a professional and technical component.

8. Historical information

CPT 48510 was added to the Current Procedural Terminology system on January 1, 1990. The code description was changed on January 1, 2014, to specify that the procedure involves external drainage of a pancreatic pseudocyst using an open incision. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A surgeon performing an open incision to drain a pancreatic pseudocyst in a patient with pancreatitis.
2. A gastroenterologist performing an external drainage procedure for a large pancreatic pseudocyst in a patient with a history of chronic pancreatitis.
3. A general surgeon performing an open incision to drain a pancreatic pseudocyst in a patient with an acute episode of pancreatitis.
4. An interventional radiologist performing an external drainage procedure for a pancreatic pseudocyst using image guidance.
5. A hepatobiliary surgeon performing an open incision to drain a pancreatic pseudocyst in a patient with a pancreatic injury.
6. A surgical oncologist performing an external drainage procedure for a pancreatic pseudocyst in a patient with pancreatic cancer.
7. A pediatric surgeon performing an open incision to drain a pancreatic pseudocyst in a child with a history of pancreatitis.
8. An interventional radiologist performing an external drainage procedure for a pancreatic pseudocyst in a patient with a pancreatic abscess.
9. A transplant surgeon performing an open incision to drain a pancreatic pseudocyst in a patient who has undergone a pancreas transplant.
10. An emergency medicine physician performing an external drainage procedure for a pancreatic pseudocyst in a patient with severe abdominal pain and suspected pancreatitis.