Question:
What documentation does my doctor need to dictate to allow code 49405–49407 as opposed to 10160?
Answer:
Codes 49405–49407 are specified as “drainage.” According to the AMA, “drainage” requires placement of an indwelling catheter. If the fluid is removed via a needle or catheter that is not left in place, then the procedure is considered “aspiration” and not drainage. So, your doctor needs to document whether a catheter was left in place or not.
CPT® copyright 2024 American Medical Association (AMA). All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
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