Question: Which code should I report if the radiologist performed a computed tomography (CT) guided aspiration of a liver cyst? New Orleans Subscriber
Answer: If the radiologist performs both the radiologic guidance and the cyst aspiration, you should report two codes: 47011 (Hepatotomy; for percutaneous drainage of abscess or cyst, one or two stages) and 75989 (Radiological guidance [i.e., fluoroscopy, ultrasound, or computed tomography], for percutaneous drainage [e.g., abscess, specimen collection], with placement of catheter, radiological supervision and interpretation). Radiology coders often mistakenly report only the radiologic guidance code for this service, but according to the March 1998 CPT Assistant , "If the physician performs both the percutaneous abscess drainage and the radiologic guidance, it would be necessary to report two codes. This is known as component coding wherein two (or more) codes are reported to accurately describe the services performed by the physician."
It advises, however, that if one physician performs the percutaneous abscess drainage (e.g., code 44901) and a different physician provides the radiological supervision and interpretation (e.g., code 75989), each physician would report only one code.