2025 CPT code 33016
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Cardiovascular System Feed
Pericardiocentesis, including imaging guidance.
Modifiers may be applicable in certain situations, such as modifier 26 (professional component) if only the interpretation of imaging is performed, or modifier 52 (reduced services) if the procedure is terminated prematurely.
Medical necessity for 33016 must be established by documenting the presence of a pericardial effusion causing symptoms or posing a risk to the patient's health. The documentation should support the need for fluid removal.
The physician prepares and anesthetizes the patient, selects a puncture site, makes a small incision (if necessary), and advances a needle attached to a syringe or suction device into the pericardial space. Imaging guidance is often used.Fluid is aspirated, and the needle is withdrawn.
In simple words: This procedure involves using a needle to drain fluid from the sac around the heart, often using imaging technology like ultrasound or x-ray to guide the needle. The healthcare provider inserts a needle through the chest wall into the pericardium to drain fluid buildup. Imaging guidance is typically used to help ensure accurate needle placement.
Pericardiocentesis, including imaging guidance, when performed. This code encompasses the procedure of puncturing the pericardium to aspirate fluid, including the use of imaging guidance like fluoroscopy or ultrasound if performed.It is used when a catheter or other drainage device is not left indwelling.
Example 1: A patient presents with shortness of breath and chest pain. Imaging reveals a pericardial effusion. 33016 is performed to remove the fluid for diagnostic and therapeutic purposes., Following a cardiac surgery, a patient develops a small pericardial effusion. To avoid potential complications, a pericardiocentesis (33016) is performed to drain the fluid., A patient with suspected cardiac tamponade undergoes 33016 for urgent drainage and hemodynamic stabilization.
Documentation should include the indication for the procedure, type of imaging guidance used (if any), amount and character of fluid aspirated, and the patient's response to the procedure. Any complications should also be documented.
** Code 33016 is specific for diagnostic or therapeutic pericardiocentesis without leaving a catheter. Distinct codes exist for pericardial drainage with catheter insertion (33017-33019).
- Payment Status: Active
- Modifier TC rule: Modifier TC is not applicable as imaging guidance is included in the code.
- Specialties:Cardiology, Cardiothoracic Surgery, Interventional Radiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Physician's Office