ED Coding and Reimbursement Alert

Question: A 50-year-old male patient is brought to the ED via ambulance; the emergency medical technician (EMT) tells the physician that the patient was mostly complaining of right-sided chest pain during the ride to the hospital; the physician provides a levelfive E/M service while stabilizing the patient; during the E/M, the physician discovers that the patient has been experiencing shortness of breath for a month, a moderate cough for the past three weeks, and occasional night sweats. A two-view chest X-ray reveals a moderate right pleural effusion. The physician performs thoracentesis, which reveals gross purulent material; the physician uses a needle and catheter tube to drain the fluid from the patient's chest cavity. Since the physician's procedure was more  extensive than simply inserting a needle, what code should be assigned?

Minnesota Subscriber

Answer: In your scenario, the physician performed therapeutic thoracentesis. On the claim, report the following:

• 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]) for the thoracentesis
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99285 to show that the E/M and the thoracentesis were separate services.

Breakdown: Therapeutic thoracentesis is performed by inserting a catheter in the pleural cavity to drain a significant amount of fluid. During these procedures, the physician utilizes a needle to enter the pleural cavity as well as a catheter tube to promote additional drainage until the procedure is completed. If you see evidence of catheter use during thoracentesis, it is likely a 32422 encounter.

Important note: This procedure should not be confused with a formal tube thoracostomy as described by code 32551. The physician typically uses only a syringe and needle to perform diagnostic thoracentesis (32421, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent). Unlike a 32422 service, 32421 encounters rarely involve a catheter.