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.

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