How To Use CPT Code 49082

CPT 49082 describes the procedure of abdominal paracentesis without imaging guidance. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49082?

CPT 49082 is used to describe the surgical puncture of the abdominal cavity for the removal of fluid without relying on any type of imaging guidance. This procedure is performed to relieve pressure and pain or to obtain a sample for laboratory analysis.

2. Official Description

The official description of CPT code 49082 is: ‘Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance.’

3. Procedure

1. During the procedure, the provider makes an incision in the abdomen after appropriately prepping and anesthetizing the patient.
2. A needle is inserted through the incision, followed by the insertion of a catheter.
3. The provider removes the needle, allowing drainage of the fluid from the abdomen through the catheter.
4. After the fluid has been drained, the provider removes the catheter, checks for any bleeding, and closes the incision.

4. Qualifying circumstances

CPT 49082 is performed when there is an abnormal buildup of fluid in the abdominal cavity that needs to be drained for diagnostic or therapeutic purposes. This procedure does not involve the use of any imaging guidance to view internal structures.

5. When to use CPT code 49082

CPT code 49082 should be used when the provider performs abdominal paracentesis without the use of imaging guidance. It is important to note that if imaging guidance is used during the procedure, a different CPT code (49083) should be reported.

6. Documentation requirements

To support a claim for CPT 49082, the provider must document the following information:

• Reason for performing the abdominal paracentesis
• Details of the procedure, including the incision, insertion of the catheter, and closure of the incision
• Any complications or adverse events that occurred during or after the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 49082, ensure that the procedure was performed without the use of imaging guidance. It is important to follow the specific guidelines provided by the payer regarding documentation and coding requirements for this procedure.

8. Historical information

CPT 49082 was added to the Current Procedural Terminology system on January 1, 2012. There have been no updates to the code since its addition.

9. Examples

1. A provider performs abdominal paracentesis without imaging guidance to relieve pressure and pain in a patient with ascites.
2. During a diagnostic procedure, a provider performs abdominal paracentesis without imaging guidance to obtain a fluid sample for laboratory analysis.
3. A patient with a large amount of fluid buildup in the abdomen undergoes therapeutic abdominal paracentesis without imaging guidance to alleviate discomfort.
4. A provider performs abdominal paracentesis without imaging guidance to drain fluid from the abdominal cavity in a patient with peritonitis.
5. During a palliative care procedure, a provider performs abdominal paracentesis without imaging guidance to provide relief to a patient with advanced cancer.
6. A provider performs abdominal paracentesis without imaging guidance to drain fluid from the abdomen in a patient with liver cirrhosis.
7. During a diagnostic procedure, a provider performs abdominal paracentesis without imaging guidance to investigate the cause of a patient’s abdominal pain.
8. A patient with a recurrent buildup of fluid in the abdomen undergoes therapeutic abdominal paracentesis without imaging guidance to improve symptoms.
9. A provider performs abdominal paracentesis without imaging guidance to obtain a fluid sample for analysis in a patient with suspected infection.
10. During a therapeutic procedure, a provider performs abdominal paracentesis without imaging guidance to relieve discomfort in a patient with congestive heart failure.