How To Use CPT Code 49185

CPT 49185 describes the percutaneous sclerotherapy of a fluid collection, such as a lymphocele, cyst, or seroma, using imaging guidance and radiological supervision and interpretation. 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 49185?

CPT 49185 can be used to describe the percutaneous sclerotherapy of a fluid collection, such as a lymphocele, cyst, or seroma. This procedure involves the destruction of the fluid collection using a chemical solution, typically ethanol, injected directly into the cavity. The procedure is performed under imaging guidance, such as ultrasound or fluoroscopy, to ensure accurate placement of the needle and to enhance visualization. Radiological supervision and interpretation are also included in this code.

2. Official Description

The official description of CPT code 49185 is: ‘Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed.’

3. Procedure

1. The provider prepares the patient for the procedure and administers anesthesia if necessary.
2. Using imaging guidance, such as ultrasound or fluoroscopy, the provider inserts a needle through a small incision in the skin and advances it to the fluid collection.
3. A guide wire is then inserted through the needle, and a catheter is advanced over the guide wire into the fluid collection.
4. The provider may withdraw some fluid for analysis and inject contrast material to enhance visualization.
5. A solution, typically ethanol, is injected directly into the fluid-filled cavity, causing the walls of the cavity to scar and collapse.
6. The collapsed wall is reabsorbed into the surrounding tissue over time.
7. The catheter is then removed, and the incision is closed.

4. Qualifying circumstances

CPT 49185 is used for patients with fluid collections, such as lymphoceles, cysts, or seromas, that require sclerotherapy. The procedure must be performed percutaneously, meaning through a small incision in the skin. Imaging guidance, such as ultrasound or fluoroscopy, is used to ensure accurate placement of the needle and to enhance visualization. Radiological supervision and interpretation are also included in this code.

5. When to use CPT code 49185

CPT code 49185 should be used when a provider performs percutaneous sclerotherapy of a fluid collection, such as a lymphocele, cyst, or seroma, using imaging guidance and radiological supervision and interpretation. This code should be reported once for each day that the procedure is performed on a separate lesion. If multiple lesions are treated through the same catheter, only one instance of CPT code 49185 should be reported.

6. Documentation requirements

To support a claim for CPT 49185, the provider must document the following information:

• Patient’s diagnosis and the need for sclerotherapy
• Specific details of the procedure, including the type of fluid collection, the use of imaging guidance, and the sclerosant used
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures or interventions performed during the same session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 49185, ensure that the procedure meets the criteria outlined in the official description. The use of imaging guidance and radiological supervision and interpretation should be documented and supported by medical necessity. It is important to review CPT and payer-specific guidelines to ensure accurate reporting. Additionally, be aware of any payer policies regarding coverage of sclerotherapy for fluid collections.

8. Historical information

CPT 49185 was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates to the code since its addition.

9. Examples

1. A provider performs percutaneous sclerotherapy of a lymphocele using ultrasound guidance and injects ethanol into the cavity to collapse the walls.
2. Using fluoroscopy, a provider performs percutaneous sclerotherapy of a cyst and injects a sclerosant solution to scar and collapse the walls.
3. A patient with a seroma undergoes percutaneous sclerotherapy, guided by ultrasound, to treat the fluid collection.
4. A provider performs percutaneous sclerotherapy of a lymphocele, using contrast injection and imaging guidance, to effectively treat the condition.
5. Using fluoroscopy, a provider performs percutaneous sclerotherapy of a cyst, injecting a sclerosant solution to promote scarring and collapse of the walls.
6. A patient with a seroma undergoes percutaneous sclerotherapy, guided by ultrasound, to resolve the fluid collection.
7. A provider performs percutaneous sclerotherapy of a lymphocele, using contrast injection and imaging guidance, to successfully treat the condition.
8. Using fluoroscopy, a provider performs percutaneous sclerotherapy of a cyst, injecting a sclerosant solution to induce scarring and collapse of the walls.
9. A patient with a seroma undergoes percutaneous sclerotherapy, guided by ultrasound, to address the fluid collection.
10. A provider performs percutaneous sclerotherapy of a lymphocele, using contrast injection and imaging guidance, to treat the condition effectively.