2025 CPT code 49406

Image-guided drainage of fluid collection by catheter placement (e.g., abscess, hematoma, seroma, lymphocele, cyst) in the peritoneal or retroperitoneal space, percutaneous approach.

The code describes a drainage procedure, which implies leaving the catheter in place. If the fluid is aspirated and no catheter is left, a different code (e.g., 10160) may be more appropriate. The documentation should clearly state whether or not a catheter was left in place.

Modifiers may be applicable. Refer to current CPT guidelines for appropriate modifier usage.

Medical necessity must be established by documenting the patient's symptoms, diagnostic findings confirming the presence of the fluid collection (e.g., abscess, hematoma), and the clinical rationale for percutaneous drainage. The documentation must support that less invasive procedures are not appropriate or have failed.

The physician is responsible for performing the entire procedure, including image guidance, skin incision, catheter insertion, and ensuring proper drainage. They must also monitor the patient's condition and manage any potential complications.

IMPORTANT Do not report 49406 in conjunction with 75989, 76942, 77002, 77003, 77012, 77021. For abdominal paracentesis, see 49082, 49083. For transrectal or transvaginal image-guided drainage, use 49407. For open transrectal drainage of pelvic abscess, use 45000. For open peritoneal or retroperitoneal drainage, see related codes for specific conditions (e.g., appendiceal abscess 44900, peritoneal abscess 49020). For percutaneous insertion of a tunneled intraperitoneal catheter without subcutaneous port, use 49418.

In simple words: Using imaging technology like ultrasound or X-ray, the doctor inserts a small tube through your skin into your belly or the area behind it to drain excess fluid or collections like cysts or abscesses. The tube is left in place to continue draining the fluid.

This code describes a procedure where a catheter is inserted through the skin into the peritoneal (abdominal) or retroperitoneal (behind the abdomen) space to drain accumulated fluid collections like abscesses, hematomas, seromas, lymphoceles, or cysts. The entire procedure is guided by imaging technology such as ultrasound, fluoroscopy, or CT scan, ensuring accurate catheter placement and drainage.The catheter is left in place at the end of the procedure to facilitate continued drainage. This procedure is percutaneous, meaning it's performed through the skin without a surgical incision.

Example 1: A patient presents with a retroperitoneal hematoma following trauma.A CT scan confirms the presence and size of the hematoma. Under CT guidance, a catheter is inserted percutaneously to drain the hematoma and is left in place for continued drainage., A patient with a history of abdominal surgery develops a peritoneal abscess. Ultrasound imaging is used to locate the abscess, and a drainage catheter is inserted percutaneously under ultrasound guidance.The catheter is left in for continued drainage., A patient undergoes a kidney transplant and subsequently develops a lymphocele. The lymphocele is localized using imaging, and percutaneous drainage is performed with catheter placement under image guidance.

Documentation should include: type of imaging guidance used; location and size of the fluid collection; percutaneous approach confirmation; type of catheter placed; confirmation that the catheter was left in place; amount of fluid drained initially; any complications encountered.

  • Specialties:Interventional Radiology, General Surgery, and other specialties depending on the clinical scenario.
  • Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, and other places of service depending on the patient's condition and the complexity of the procedure.
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