ED Coding and Reimbursement Alert

Question: A patient with shortness of breath reports to the ED. The physician obtains pertinent historical information and performs an exam, including auscultation of the lungs, which sound muffled. He then taps on the patient's chest and notes a dull "thud." A chest x-ray confirms the presence of a large pleural effusion. Notes substantiate a level-four E/M. Based on the evaluation, the physician decides to perform thoracentesis. After the patient is prepped, the physician withdraws pleural fluid through a needle into a syringe and sends it to the laboratory for analysis. The lab results indicate the presence of an exudative pleural effusion. How should I code this encounter? Nebraska Subscriber Answer: This is an example of a thoracentesis. Report the following: - 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for the thoracentesis - 511.9 (Unspecified pleural effusion) linked to 32421 to represent the pleural effusion - 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M - modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99284 to show that the E/M and thoracentesis were separate services - 786.05 (Shortness of breath) linked to 99284 to represent the patient's breathing difficulty - 71020 (Radiologic examination, chest, two views, frontal and lateral) for the x-ray - modifier 26 (Professional component) linked to 71020 to show that you are only coding for the professional portion of the code - 511.9 linked to 71020 to represent the effusion. Thoracentesis types: For some pleural effusion patients, the ED physician needs to sample the pleural fluid for analysis. When the physician performs thoracentesis in order to diagnose the patient's condition, you-ll report the service with 32421. But during other thoracentesis procedures, the physician inserts a needle into the pleural cavity, inserts a catheter to drain pleural fluid, and then removes the needle. (During this type of thoracentesis, the catheter remains in place for the entire procedure). When the physician performs thoracentesis with catheter insertion, you should code the service with 32422 (Thoracentesis with insertion of chest tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]).