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Official Description

Aspiration and/or injection of ganglion cyst(s) any location

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 20612 involves the aspiration and/or injection of ganglion cysts, which can occur in various locations within the body. A ganglion cyst is a non-cancerous, fluid-filled sac that typically forms near joints or tendons, often resulting from irritation or injury. These cysts are composed of ganglion cells and contain a thick, jelly-like fluid. During the procedure, the physician first administers local anesthesia to minimize discomfort for the patient. Following anesthesia, a needle is carefully inserted into the cyst or cysts. The physician may then aspirate, or withdraw, the viscous fluid from the cyst, which can help alleviate symptoms such as pain or swelling. Alternatively, the physician may inject a substance, such as a corticosteroid, into the cyst to reduce inflammation and promote healing. This procedure is commonly performed in an outpatient setting and is generally well-tolerated by patients.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The aspiration and/or injection of ganglion cysts is typically indicated for the following conditions:

  • Pain or Discomfort Patients experiencing pain or discomfort due to the presence of a ganglion cyst may require this procedure to alleviate symptoms.
  • Swelling Ganglion cysts can cause localized swelling, which may necessitate intervention to reduce the size of the cyst and improve the appearance of the affected area.
  • Functional Impairment If a ganglion cyst interferes with joint movement or function, the procedure may be indicated to restore normal function.

2. Procedure

The procedure for aspiration and/or injection of ganglion cysts involves several key steps:

  • Step 1: Preparation The physician prepares the patient by explaining the procedure and obtaining informed consent. The area around the ganglion cyst is cleaned and sterilized to minimize the risk of infection.
  • Step 2: Anesthesia Administration Local anesthesia is administered to the patient to ensure comfort during the procedure. This may involve the injection of a local anesthetic agent around the cyst.
  • Step 3: Needle Insertion A sterile needle is carefully inserted into the ganglion cyst. The physician may use ultrasound guidance to accurately locate the cyst and ensure proper needle placement.
  • Step 4: Aspiration If aspiration is indicated, the physician withdraws the viscous fluid from the cyst using a syringe attached to the needle. This step helps to relieve pressure and discomfort associated with the cyst.
  • Step 5: Injection (if applicable) If an injection is part of the procedure, the physician may inject a corticosteroid or other therapeutic agent into the cyst to reduce inflammation and promote healing.
  • Step 6: Post-Procedure Care After the aspiration and/or injection, the needle is removed, and a sterile dressing may be applied to the site. The physician provides post-procedure instructions to the patient regarding care and any potential follow-up.

3. Post-Procedure

Post-procedure care for patients who have undergone aspiration and/or injection of ganglion cysts typically includes monitoring for any immediate complications, such as infection or excessive bleeding. Patients are advised to keep the area clean and dry, and they may be instructed to avoid strenuous activities or heavy lifting for a specified period. Pain relief can often be managed with over-the-counter analgesics, and patients should be informed about signs of complications that would warrant immediate medical attention. Follow-up appointments may be scheduled to assess the effectiveness of the procedure and determine if further treatment is necessary.

Short Descr ASPIRATE/INJ GANGLION CYST
Medium Descr ASPIRATION&/INJECTION GANGLION CYST ANY LOCATJ
Long Descr Aspiration and/or injection of ganglion cyst(s) any location
Status Code Active Code
Global Days 000 - Endoscopic or 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) P6C - Minor procedures - other (Medicare fee schedule)
MUE 2
CCS Clinical Classification 156 - Injections and aspirations of muscles, tendons, bursa, joints and soft tissue

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)
RT Right side (used to identify procedures performed on the right side of the body)
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).
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.
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.
F7 Right hand, third digit
F5 Right hand, thumb
FA Left hand, thumb
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.)
F2 Left hand, third digit
T7 Right foot, third digit
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m 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).
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.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
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
E4 Lower right, eyelid
EJ Subsequent claims for a defined course of therapy, e.g., epo, sodium hyaluronate, infliximab
F1 Left hand, second digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F6 Right hand, second digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
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
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
GZ Item or service expected to be denied as not reasonable and necessary
HV Funded state addictions agency
KX Requirements specified in the medical policy have been met
PN Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
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
SA Nurse practitioner rendering service in collaboration with a physician
SG Ambulatory surgical center (asc) facility service
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T8 Right foot, fourth digit
TA Left foot, great toe
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
X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
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
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
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
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
2013-01-01 Changed Medium Descriptor changed.
2003-01-01 Added First appearance in code book in 2003.
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