We continue to discuss soft tissue masses. A patient presented with a soft tissue mass on the dorsolateral aspect of the left foot. She noticed the mass several months ago. It was small and she kept an eye on it. Within the last 5 weeks it has grown rapidly and causes discomfort in certain shoes. She has recently been diagnosed with breast cancer and is undergoing treatment. She is afraid that the mass may represent “something to be concerned about.”
Image 1 represents the mass on the longitudinal axis. The extensor digitorum longus tendon (EDL) is visible. The internal aspect of the mass (m) is anechoic The mass is fully compressible, well encapsulated, and has posterior acoustic (PA) enhancement. This posterior acoustic enhancement, which is the hyperechoic signal deep to the mass, is characteristic of the mass being fluid-filled and not solid. All of these characteristics are suggestive of a ganglion cyst. Aspiration was decided upon. There are two guided injection or aspiration techniques. The out-of-plane technique is what I utilized to aspirate this cyst [Image 2]. This technique [Photo 1] gives you a small acoustic window to visualize the needle. All you will see is the tip of the needle. The in-plane technique [Photo 2] will allow you to see the length of the needle. I attempted the in-plane technique first, but was unable to penetrate the capsule of the mass buy used commercial inflatable water slides. The mass would move with the needle pressure. When I switched to the out-of-plane technique [Image 2], I gained more control and was able to apply opposing force on the mass while penetrating the capsule. The cyst was aspirated [Photo 3 and Image 3] and confirmed as a ganglion cyst.
There are three scenarios possible with how this was coded:
76881 – This is a comprehensive diagnostic exam. This exam usually takes 30 minutes and is a survey of the ankle. In this exam, you are unsure of what is injured and/or causing the pain. You would have 15 to 20 saved images with labels. If I chose this option and found the cyst, this code would be an appropriate.
76882 – This is a site-specific code. You have narrowed the area of insonation to a specific site and/or structure. The exam is quicker and you need fewer saved images and less documentation. This is the type of exam I performed.
76942 – This is the ultrasound-guided injection or aspiration code.
If you perform an ultrasound that reveals the pathology and you decide at the same visit to inject or aspirate, can you code a 76881 or 76882 and also a 76942? In theory, it seems that you should be able to so. The 76881 or 76882 are diagnostic codes and the 76942 is a procedural code. It has been explained to me that the diagnostic exam is bundled in the 76942, so you bill only for the 76942.