ED Coding and Reimbursement Alert

Question: Encounter notes indicate that the ED physician inserted a long needle into the space between the lungs and chest wall. They performed this insertion in order to remove fluid from the space. How should I report this encounter?

Arkansas Subscriber

Answer: This is thoracentesis. You’ll need a bit more information in order to code correctly.

Do this: Go back and look at the encounter notes to see if there is any mention of guidance used during the procedure. If there is no mention of guidance, report 32554 (Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance). If the notes indicate that guidance was used, report 32555 (… with imaging guidance).