ED Coding and Reimbursement Alert

Question: A patient with shortness of breath reports to the ED. The physician documents the pertinent historical information and performs an exam including auscultation of the lungs, which sound muffled.  Percussing the patient’s chest produces a dull “thud.” A chest X-ray interpreted by the emergency physician confirms the presence of a large pleural effusion.

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 After the patient is prepped, pleural fluid is withdrawn through a needle into a syringe and sent to the laboratory for analysis.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 assuming the rest of the chart documentation supports a level-five ED E/M service?

Nebraska Subscriber

Answer: The scenario described 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 without leaving in a catheter or tube, you’ll report the service with 32554 (Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance).

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, leaving the catheter in place for the entire procedure).

When the physician performs thoracentesis with catheter insertion, code the service with 32556 (Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance)

On the claim, report the following:

• 32554 (Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance);
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high 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 99285 to show that the E/M and thoracentesis were separate services;
• 71020 (Radiologic examination, chest, two views, frontal and lateral) for the X-ray; and
• Modifier 26 (Professional component) linked to 71020 to show you are only coding for the professional portion of the code.

Don’t forget to demonstrate medical necessity by appending these ICD-10 codes:

• J91.8 (Pleural effusion in other conditions classified elsewhere) linked to 32554 to represent the pleural effusion and
• R06.02 (Shortness of breath) linked to 99285 and 71020 to represent the patient’s breathing difficulty.