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 After the patient is prepped, pleural fluid is withdrawn through a needle into a syringe and sent to the laboratory for analysis. The results indicate the presence of an exudative pleural effusion. How would you code for this encounter? Nevada Subscriber Answer: This is an example of thoracentesis. For some pleural effusion patients, the ED physician needs to sample the pleural fluid for analysis. When the physician performs thoracentesis removing accumulated fluid from the pleural space but not leaving in a catheter or [...]