How To Use CPT Code 49422

CPT 49422 describes the procedure for the removal of a tunneled intraperitoneal catheter. 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 49422?

CPT 49422 can be used to describe the removal of a tunneled intraperitoneal catheter. This code is used when a healthcare provider removes an existing catheter that is used to drain a recurrent accumulation of fluid in the abdomen. The procedure involves making an incision over the site where the catheter enters the abdomen, dissecting scar tissue, excising the catheter, irrigating the area, and closing the wound in layers.

2. Official Description

The official description of CPT code 49422 is: ‘Removal of tunneled intraperitoneal catheter (For removal of a non-tunneled catheter, use appropriate E/M code)’

3. Procedure

1. The healthcare provider prepares the patient for the procedure and administers anesthesia.
2. An incision is made over the site where the catheter enters the abdomen.
3. The provider carefully dissects scar tissue to free up the catheter.
4. The catheter is excised, and the area is irrigated with an antibiotic solution.
5. The tunneled tubing may be gently pulled free or require additional dissection for removal.
6. A drain may be left in place for further drainage during healing.
7. The provider achieves hemostasis, removes any instruments, and closes the wound in layers.

4. Qualifying circumstances

Patients eligible for CPT 49422 are those with a tunneled intraperitoneal catheter that requires removal. This procedure is performed when there is a recurrent accumulation of fluid in the abdomen. The healthcare provider must carefully assess the patient’s condition and determine the need for catheter removal. It is important to note that this code is specifically for the removal of a tunneled catheter, and a different code should be used for the removal of a non-tunneled catheter.

5. When to use CPT code 49422

CPT code 49422 should be used when a healthcare provider performs the procedure to remove a tunneled intraperitoneal catheter. It is important to ensure that the catheter being removed is tunneled and not non-tunneled, as the appropriate E/M code should be used for the removal of a non-tunneled catheter.

6. Documentation requirements

To support a claim for CPT 49422, the healthcare provider must document the following information:

• Patient’s medical history and the need for catheter removal
• Details of the procedure, including the incision site, dissection of scar tissue, excision of the catheter, and irrigation of the area
• Use of anesthesia and any complications encountered
• Presence of a drain and any post-procedure instructions
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 49422, ensure that the procedure involves the removal of a tunneled intraperitoneal catheter. If the catheter being removed is non-tunneled, the appropriate E/M code should be used instead. It is important to follow the specific guidelines and coding instructions provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 49422 was added to the Current Procedural Terminology system on January 1, 1995. There was a code change on January 1, 2011, which updated the description to specify the removal of a permanent intraperitoneal cannula or catheter.

9. Examples

1. A healthcare provider removes a tunneled intraperitoneal catheter used for draining fluid in the abdomen.
2. A patient undergoes a procedure to have a tunneled catheter removed due to recurrent fluid accumulation.
3. A healthcare provider performs the removal of a tunneled intraperitoneal catheter and ensures proper wound closure.
4. A patient’s tunneled catheter is excised, and the area is irrigated to prevent infection.
5. A healthcare provider removes a tunneled intraperitoneal catheter and assesses the need for further drainage during the healing process.
6. A patient undergoes a procedure to remove a tunneled catheter, and the wound is closed in layers to promote proper healing.
7. A healthcare provider carefully dissects scar tissue to free up a tunneled intraperitoneal catheter for removal.
8. A patient’s tunneled catheter is excised, and the area is thoroughly irrigated with an antibiotic solution.
9. A healthcare provider achieves hemostasis after removing a tunneled intraperitoneal catheter and ensures the wound is properly closed.
10. A patient’s tunneled catheter is gently pulled free during the removal procedure, and the wound is closed to promote healing.