How To Use CPT Code 49407

CPT 49407 describes the procedure of image-guided fluid collection drainage by catheter in the peritoneal or retroperitoneal area, performed transvaginally or transrectally. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49407?

CPT 49407 can be used to describe the image-guided drainage of fluid collections in the peritoneal or retroperitoneal area using a catheter. This procedure is performed transvaginally or transrectally, with the guidance of imaging techniques such as ultrasound, fluoroscopy, or computed tomography. The catheter is inserted through the vaginal or rectal wall to drain the fluid from the targeted area.

2. Official Description

The official description of CPT code 49407 is: ‘Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal.’

3. Procedure

1. The healthcare provider uses imaging guidance, such as ultrasound, fluoroscopy, or computed tomography, to direct a catheter through the vaginal or rectal wall to the peritoneal or retroperitoneal area.
2. A hollow needle is inserted through the vaginal or rectal wall into the area where the fluid collection is located.
3. A guide wire is passed through the needle to create a path for the drainage catheter.
4. The drainage catheter is placed into the area of fluid under the guidance of imaging techniques.
5. The fluid collection is drained, and the catheter is left in place to ensure continued drainage.

4. Qualifying circumstances

CPT 49407 is performed on patients with fluid collections in the peritoneal or retroperitoneal area that require drainage. The procedure is typically done transvaginally or transrectally, and image guidance is used to ensure accurate catheter placement. It is important to note that CPT 49407 should not be reported in conjunction with codes 75989, 76942, 77002, 77003, 77012, or 77021. Additionally, each individual fluid collection drained with a separate catheter should be reported separately using codes 49405, 49406, or 49407.

5. When to use CPT code 49407

CPT code 49407 should be used when a healthcare provider performs image-guided fluid collection drainage by catheter in the peritoneal or retroperitoneal area, using a transvaginal or transrectal approach. This code should not be used in conjunction with certain other codes, as mentioned in the qualifying circumstances section.

6. Documentation requirements

To support a claim for CPT 49407, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for fluid collection drainage
• Imaging guidance used (ultrasound, fluoroscopy, or computed tomography)
• Date and details of the procedure, including the approach (transvaginal or transrectal)
• Specific fluid collection drained and the catheter used
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 49407, ensure that the procedure is performed using the transvaginal or transrectal approach for drainage in the peritoneal or retroperitoneal area. It is important to follow the guidelines and not report CPT 49407 in conjunction with certain other codes. Additionally, each individual fluid collection drained with a separate catheter should be reported separately using the appropriate codes.

8. Historical information

CPT 49407 was added to the Current Procedural Terminology system on January 1, 2014. There have been no updates to the code since its addition.

9. Examples

1. A radiologist performing image-guided drainage of a peritoneal abscess using a transvaginal approach.
2. An interventional radiologist using ultrasound guidance to drain a retroperitoneal hematoma transrectally.
3. A gynecologist performing transvaginal drainage of a seroma in the peritoneal area under fluoroscopic guidance.
4. An oncologist using computed tomography guidance to drain a lymphocele in the retroperitoneal area transrectally.
5. An interventional radiologist performing transvaginal drainage of a cyst in the peritoneal area using fluoroscopy.
6. A urologist using transrectal ultrasound guidance to drain a retroperitoneal abscess.
7. A gastroenterologist performing transvaginal drainage of a peritoneal hematoma under computed tomography guidance.
8. An interventional radiologist using fluoroscopy to drain a retroperitoneal seroma transrectally.
9. A gynecologist performing transvaginal drainage of a lymphocele in the peritoneal area under ultrasound guidance.
10. An oncologist using computed tomography guidance to drain a cyst in the retroperitoneal area transrectally.