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

Puncture aspiration of abscess, hematoma, bulla, or cyst

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 10160 involves the puncture aspiration of an abscess, hematoma, bulla, or cyst. This technique is utilized to remove accumulated fluid from a localized area beneath the skin, which may be causing discomfort, swelling, or other symptoms. The term 'puncture aspiration' refers to the process of using a needle to penetrate the skin and access the fluid-filled cavity, allowing for the extraction of the fluid through suction. This method is less invasive compared to incision and drainage procedures, as it typically requires only a small puncture rather than a larger surgical incision. The physician begins by cleansing the skin over the area where the fluid is located, ensuring a sterile environment to minimize the risk of infection. A large needle, which is connected to a syringe, is then carefully inserted into the fluid deposit. The physician aspirates the fluid by pulling back on the syringe plunger, effectively drawing the fluid out of the body. Following the aspiration, a pressure dressing may be applied to the site to help control any bleeding and to support the healing process. This procedure is commonly performed in outpatient settings and is essential for managing conditions that involve fluid accumulation, providing relief to the patient while minimizing recovery time.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 10160 is indicated for the following conditions:

  • Abscess - A localized collection of pus that can cause pain and swelling, requiring drainage to alleviate symptoms.
  • Hematoma - A localized collection of blood outside of blood vessels, often resulting from trauma, which may need aspiration to reduce pressure and discomfort.
  • Bulla - A fluid-filled blister that can occur due to various skin conditions or injuries, which may require aspiration to relieve pressure or prevent rupture.
  • Cyst - A closed sac-like structure filled with fluid or semi-solid material that can become symptomatic, necessitating aspiration for relief.

2. Procedure

The procedure for puncture aspiration as outlined in CPT® Code 10160 involves several key steps:

  • Step 1: Skin Cleansing - The physician begins by thoroughly cleansing the skin over the area where the fluid deposit is located. This step is crucial to reduce the risk of infection and ensure a sterile environment for the procedure.
  • Step 2: Needle Insertion - A large needle, which is attached to a syringe, is carefully guided into the fluid deposit. The physician must ensure proper placement of the needle to effectively access the fluid without causing unnecessary trauma to surrounding tissues.
  • Step 3: Aspiration - Once the needle is in place, the physician aspirates the fluid by pulling back on the syringe plunger. This action creates a vacuum that draws the fluid out of the cavity and into the syringe, allowing for its removal from the body.
  • Step 4: Dressing Application - After the aspiration is complete, a pressure dressing may be applied over the site of the procedure. This dressing helps to control any bleeding that may occur and supports the healing process by providing compression to the area.

3. Post-Procedure

Following the puncture aspiration procedure, patients may be advised to monitor the site for any signs of infection, such as increased redness, swelling, or discharge. It is important for patients to keep the area clean and dry, following any specific aftercare instructions provided by the physician. The application of a pressure dressing may help in managing any residual fluid accumulation and promoting healing. Patients are typically able to resume normal activities shortly after the procedure, but they should avoid strenuous activities that could stress the site until it has fully healed. Follow-up appointments may be scheduled to assess the site and ensure proper recovery.

Short Descr PNXR ASPIR ABSC HMTMA BULLA
Medium Descr PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST
Long Descr Puncture aspiration of abscess, hematoma, bulla, or cyst
Status Code Active Code
Global Days 010 - Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory 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 Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6A - Minor procedures - skin
MUE 3
CCS Clinical Classification 170 - Excision of skin lesion

This is a primary code that can be used with these additional add-on codes.

77002 CPT Add On MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)
LT Left side (used to identify procedures performed on the left side of the body)
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).
RT Right side (used to identify procedures performed on the right side of the body)
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.
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
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.
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
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.)
GC This service has been performed in part by a resident under the direction of a teaching physician
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.)
TA Left foot, great toe
T7 Right foot, third digit
T5 Right foot, great toe
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
T6 Right foot, second digit
GW Service not related to the hospice patient's terminal condition
T1 Left foot, second digit
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
GZ Item or service expected to be denied as not reasonable and necessary
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
T2 Left foot, third digit
24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
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).
74 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
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.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AF Specialty physician
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
ER Items and services furnished by a provider-based, off-campus emergency department
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
FS Split (or shared) evaluation and management visit
GA Waiver of liability statement issued as required by payer policy, individual case
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
KX Requirements specified in the medical policy have been met
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
MH Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
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
Q8 Two class b findings
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
SA Nurse practitioner rendering service in collaboration with a physician
SG Ambulatory surgical center (asc) facility service
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TR School-based individualized education program (iep) services provided outside the public school district responsible for the student
X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2024-01-01 Changed Short Description changed.
Pre-1990 Added Code added.
Code
Description
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"