06/06/2018

Correct Coding for Ganglion Cyst-Left Foot-Aspirated with Needle & Injected with Dexamethasone

I had a patient with a ganglion cyst left foot.I aspirated with needle ;this produced 1 cc fluid. I then injected with dexamethasone.How is it billed?

The CPT to bill for the aspiration of the patient’s cyst is  20612

Code Description: 20612 (Aspiration and/or injection of ganglion cyst(s) any location). 

Lay Description:

The physician aspirates and/or injects a ganglion cyst. After administering a local anesthetic, the physician inserts a needle through the skin and into the ganglion cyst. A ganglion cyst is a benign mass consisting of a thin capsule containing clear, mucinous fluid arising from an aponeurosis or tendon sheath, such as on the back of the wrist or foot. A fluid sample may be withdrawn from the cyst or a medicinal substance may be injected for therapy. The needle is withdrawn and pressure is applied to stop any bleeding.

Coding Tips:

Local anesthesia is included in this service. When multiple ganglion cyst aspirations and/or injections are performed, append modifier 59 or an X{EPSU} modifier for second and subsequent ganglion cysts treated by aspiration/injection. For injection of a tendon sheath or ligament, see 20550. For arthrocentesis, aspiration, and/or injection of a small joint or bursa, see 20600-20604; intermediate joint or bursa, see 20605-20606; major joint or bursa, see 20610-20611. For aspiration and injection of a bone cyst, see 20615. For excision of a ganglion cyst, see 25111-25112. It is inappropriate to report supplies when these services are performed in an emergency room. For physician offices, supplies may be reported with the appropriate HCPCS Level II code. Check with the specific payer to determine coverage

The ICD-10 code to bill for a ganglion cyst of the left foot is M67.472 (Ganglion, left ankle and foot).