Summary & Overview
CPT 49082: Abdominal Paracentesis Without Imaging
CPT code 49082 represents an abdominal paracentesis performed without imaging guidance to remove ascitic fluid for symptom relief or diagnostic sampling. Nationally, this code captures a common bedside procedure used across acute and ambulatory care settings to address pain, respiratory compromise, or to obtain laboratory specimens. Accurate coding for 49082 affects claims processing, clinical documentation, and quality measurement related to procedural care for patients with ascites.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will encounter payer-specific coverage context and common modifier usage patterns where available, as well as implications for facility and provider billing across hospital, emergency department, and ambulatory settings.
This publication provides benchmarks and policy-relevant updates tied to procedural coding, clarifies the clinical context in which 49082 is typically used, and outlines typical sites of service. It is intended for clinical coders, billing professionals, and policy analysts seeking a concise national overview of how this CPT code is applied and documented. Data not available in the input is noted where relevant.
Billing Code Overview
CPT code 49082 describes a procedure in which a provider withdraws an abnormal buildup of fluid from the abdominal cavity to relieve pressure and pain or to obtain a sample for laboratory analysis. The procedure is performed without imaging guidance, using direct percutaneous aspiration techniques.
Service type: Therapeutic and diagnostic abdominal paracentesis performed without imaging guidance
Typical site of service: Hospital inpatient or outpatient setting, emergency department, or ambulatory surgical center, where bedside or procedure-room percutaneous aspiration can be performed without imaging support.
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 62-year-old man with cirrhosis and progressive abdominal distension presents to the outpatient clinic with increasing shortness of breath and discomfort. Physical exam demonstrates diffuse abdominal girth and shifting dullness consistent with ascites. The clinician discusses a diagnostic and potentially therapeutic paracentesis to relieve symptoms and obtain peritoneal fluid for cell count, culture, and chemistry. The procedure is performed at the bedside in an outpatient procedure room or at the hospital bedside without imaging guidance. After obtaining informed consent, the provider identifies an appropriate entry site (typically in the lower lateral abdomen), prepares the skin with antiseptic, infiltrates local anesthetic, and advances a needle/cannula to withdraw ascitic fluid. Fluid is collected into sterile containers for laboratory testing and additional aliquots sent for culture and cytology as indicated. The patient is monitored post-procedure for hemodynamic stability and complications (e.g., bleeding, bowel perforation) and discharged with wound care instructions and follow-up arranged.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of procedure | Use when an E/M visit is performed and documented in addition to the paracentesis on the same day. |