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2025 CPT code 49407

Image-guided fluid collection drainage via catheter (e.g., abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal.

Follow all applicable CPT coding guidelines and documentation requirements for accurate reporting.Accurate imaging documentation is critical for supporting the medical necessity.

Modifiers may apply depending on the circumstances of the procedure (e.g., 59 for a distinct procedural service, 76 for a repeat procedure). Consult the CPT manual for specific modifier guidelines.

Medical necessity for this procedure is established by the presence of a symptomatic fluid collection (abscess, hematoma, etc.) that is causing significant pain, infection, or other complications.The procedure is deemed medically necessary when conservative management has failed or is not feasible.

The clinical responsibility lies with a physician specializing in procedures involving image guidance and drainage of fluid collections (e.g., general surgeon, gynecologist, interventional radiologist). This might involve pre-procedure evaluation, image interpretation, catheter placement, and post-procedure monitoring.

IMPORTANT:Do not use 49407 with 75989, 76942, 77002, 77003, 77012, 77021. Report 49405, 49406, 49407 separately for each collection drained with a separate catheter. For open transrectal or transvaginal drainage, consider 45000 (pelvic abscess), 58800 (ovarian cyst), 58820 (ovarian abscess). For percutaneous image-guided fluid collection drainage in soft tissue (e.g., extremity, abdominal wall, neck), use 10030.

In simple words: The doctor uses imaging (like ultrasound) to guide a thin tube through the vagina or rectum to drain fluid from the abdomen or area around the kidneys. The tube is left in place to keep the area drained.

This CPT code 49407 describes the image-guided drainage of fluid collections (such as abscesses, hematomas, seromas, lymphoceles, or cysts) located in the peritoneal or retroperitoneal spaces.The procedure involves the placement of a catheter through either the vaginal or rectal wall, guided by imaging modalities like ultrasound, fluoroscopy, or computed tomography. The catheter is positioned to drain the fluid collection, and it's typically left in place for continued drainage.This is distinct from open surgical drainage techniques.

Example 1: A patient presents with a large pelvic abscess identified on CT scan. The physician uses transvaginal ultrasound guidance to place a catheter for drainage., A post-surgical patient develops a retroperitoneal hematoma.Under fluoroscopic guidance, a transrectal catheter is placed to drain the hematoma., A patient with a known ovarian cyst experiences significant pain and discomfort. The gynecologist uses ultrasound-guided transvaginal drainage to relieve the pressure.

** Always refer to the most current CPT codebook and payer guidelines for the most accurate and up-to-date information regarding this code.Specific payer policies regarding medical necessity and reimbursement may vary.

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