Coding Ahead
CasePilot
Medical Coding Assistant
Case2Code
Search and Code Lookup Tool
RedactPHI
HIPAA-Compliant PHI Redaction
DetectICD10CM
ICD-10-CM Code Detection
Log in Register free account
1 code page views remaining. Guest accounts are limited to 1 page view. Register free account to get 5 more views.
Log in Register free account

Official Description

Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 10030 involves the image-guided drainage of fluid collections located in soft tissues, which may include conditions such as abscesses, hematomas, seromas, lymphoceles, or cysts. These fluid collections can occur in various anatomical locations, including the extremities, abdominal wall, or neck. The term "percutaneous" indicates that the procedure is performed through the skin, minimizing the need for larger incisions. Utilizing imaging techniques such as fluoroscopy, ultrasound, or computed tomography (CT), the healthcare provider can accurately locate the fluid collection. Once identified, the skin and underlying soft tissue are punctured to insert a catheter, allowing for the drainage of the accumulated fluid. This technique not only alleviates pressure and discomfort associated with the fluid collection but also aids in the prevention of further complications. In some cases, the cavity may be irrigated with sterile saline or an antibiotic solution to ensure thorough cleansing of the area, which is crucial for promoting healing and reducing the risk of infection. The catheter may be secured to the skin to facilitate ongoing drainage as necessary, and it is typically removed once the fluid collection has been adequately managed.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure is indicated for the following conditions:

  • Abscess A localized collection of pus that can cause pain and swelling, requiring drainage to relieve symptoms and prevent further infection.
  • Hematoma A collection of blood outside of blood vessels, often resulting from trauma, which may need to be drained to alleviate pressure and promote healing.
  • Seroma A pocket of clear serous fluid that can develop after surgery or injury, necessitating drainage to reduce discomfort and prevent complications.
  • Lymphocele A collection of lymphatic fluid that can occur post-surgery or due to lymphatic obstruction, requiring drainage to manage symptoms.
  • Cyst A closed sac filled with fluid or semi-solid material that may need to be drained if it becomes symptomatic or infected.

2. Procedure

The procedure involves several key steps to ensure effective drainage of the fluid collection:

  • Step 1: Imaging Guidance The first step is to utilize imaging techniques such as fluoroscopy, ultrasound, or CT to accurately locate the fluid collection within the soft tissue. This imaging is crucial for ensuring precise targeting of the area to be drained.
  • Step 2: Skin Preparation Once the fluid collection is identified, the skin over the area is prepared and sterilized to minimize the risk of infection during the procedure.
  • Step 3: Puncture and Catheter Insertion A needle is then carefully inserted through the skin and into the fluid collection. After confirming the correct placement, a catheter is introduced through the needle to facilitate drainage of the fluid.
  • Step 4: Fluid Drainage The accumulated fluid is drained through the catheter. This step may involve the use of suction to ensure complete evacuation of the fluid.
  • Step 5: Cavity Irrigation After the fluid has been drained, the cavity may be flushed with sterile saline or an antibiotic solution. This irrigation helps to clear any remaining pus, blood, or other fluids, promoting a clean environment for healing.
  • Step 6: Catheter Securing The catheter is then secured to the skin to allow for continuous drainage as needed. This may be necessary if there is a risk of fluid re-accumulation.
  • Step 7: Monitoring and Removal The patient is monitored for any complications, and the catheter is removed once the drainage is no longer required, ensuring that the site is healing properly.

3. Post-Procedure

After the procedure, patients may require monitoring for any signs of infection or complications related to the drainage. The site where the catheter was inserted should be kept clean and dry, and patients may be advised on how to care for the area. Follow-up appointments may be necessary to assess healing and determine if further intervention is needed. The duration for which the catheter remains in place will depend on the amount of fluid being drained and the clinical judgment of the healthcare provider.

Short Descr IMG GID FLU COLL DRG SFT TIS
Medium Descr IMG-GUIDED FLU COLLJ DRG CATH SOFT TISS PERQ
Long Descr Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 9 - Not Applicable
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 9 - Concept does not apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight.
Type of Service (TOS) 1 - Medical Care
Berenson-Eggers TOS (BETOS) P6C - Minor procedures - other (Medicare fee schedule)
MUE 2
GC This service has been performed in part by a resident under the direction of a teaching physician
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
F9 Right hand, fifth digit
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
MG The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional
RT Right side (used to identify procedures performed on the right side of the body)
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2024-01-01 Changed Short and Medium Descriptions changed.
2017-01-01 Changed Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category.
2014-01-01 Added Added
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"