Gastroenterology Coding Alert

Checking for imaging guidance now helps improve reporting accuracy.

If accurately reporting a paracentesis service has been a challenge for you, particularly trying to determine whether the services were initial or subsequent and how to report any lavage that's included, there's good news. CPT® 2012 rings in some welcome modifications to the way you report paracentesis making it simple and uncomplicated.

Read on for advice on applying these changes.

Heed These Lavage, Imaging Adjustments

Before the CPT® 2012 change, you had to report both paracentesis and lavage of the peritoneum with the same code making it difficult to track what procedure your gastroenterologist actually did.

Another difficulty was that there were two codes to report paracentesis, depending on if your gastroenterologist was performing the procedure for the first time or as a follow-up to an initial procedure. "A paracentesis is performed with the same technique each time it is done with no alteration in any steps whether the patient is having the procedure for the first time or the tenth time," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel. "The documentation will look the same, so it was a very difficult problem" as often "the operative notes do not carry such information and you might have had to check back with your gastroenterologist for more information."

To alleviate this challenge, CPT® 2012 separates paracentesis and peritoneal lavage. Also, there are no separate codes for an initial and a follow-up procedure, removing the difficulty of having to analyze if it is an initial or a subsequent procedure.

The old codes (prior to Jan.1, 2012) that have now been deleted include the following:

• 49080 -- Peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; initial; and
• 49081 -- Peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; subsequent

Under CPT® 2012, you will now need to report the procedure under these codes:

• 49082 -- Abdominal paracentesis [diagnostic or therapeutic]; without imaging guidance; and
• 49083 -- Abdominal paracentesis [diagnostic or therapeutic]; with imaging guidance

When your gastroenterologist performs peritoneal lavage, then you need to report it as 49084 (Peritoneal lavage, including imaging guidance, when performed).

Capture imaging: Under the new CPT® 2012 changes, you will need to know if imaging guidance has been used for the paracentesis procedure or not, as there are two distinguishable codes (i.e. 49082 and 49083) depending on this. Look for indications of imaging in the procedure note before reporting paracentesis with imaging (49083).

Get Familiar With Abdominal Paracentesis

CPT® 2012 specifies "abdominal paracentesis" in 49082 and 49083, so a clinical refresher may be helpful in accurate code selection for these services. Abdominal paracentesis is also known by other terms such as peritoneocentesis, abdominal tap, or peritoneal tap, any of which your gastroenterologist might use in the operative notes. It is a procedure your gastroenterologist performs either in the office or in a hospital setting under local anesthesia.

Your gastroenterologist performs abdominal paracentesis either for diagnostic sampling of the fluid that has accumulated or to relieve symptoms caused due to the fluid accumulation. "If the procedure is therapeutic, a larger amount of fluid is generally drained and the patient is kept under supervision in case there is occurrence of hypotension with symptoms such as lightheadedness, palpitations, or dizziness," says Weinstein. "In some cases, it may be necessary to administer intravenous fluids to replace volume removed during a therapeutic paracentesis."

Example: Take a look at the following scenario to help you understand how the procedure is performed:

"After preparation of the abdominal tap kit, the border of the ascites was reconfirmed and a suitable site for paracentesis was identified. The patient was placed supine with the head elevated. A Foley catheter was used to clear the bladder.

After percussion to reconfirm the border, the tap site was marked in the midline 2cms under the umbilicus. A betadine swab was used to clean the area and the area was then isolated using a sterile drape. The syringe was loaded with the local anesthetic and it was penetrated into the skin at a 90 degree angle while the left hand stabilized the area of penetration. The anesthetic was then slowly injected into the area with alternate aspiration and injection. The procedure was continued till the accumulated ascitic fluid was visible inside the syringe.

A slight cut was made using a No.11 size scalpel blade to permit easy passage of the catheter. The flexible catheter was prepared and the large needle was used to enter the peritoneal space. Negative pressure was applied to help ascertain the location into the peritoneal cavity. The needle was positioned 3 cm into the peritoneal cavity to avoid displacement.

The needle was then held in place with one hand and the catheter was slowly advanced all the way over the needle. Once the catheter was in place, the needle was slowly removed. A large syringe was then attached to the stopcock. Using slow aspiration, the fluid was then collected in the syringe and stored in the vial to be sent to the laboratory for diagnosis."

Coding advice: You would report the procedure as 49082, as the paracentesis procedure described here was conducted without the use of any imaging guidance.

Don't Use 49083 with Other Radiological Codes

CPT® mandates that any imaging guidance that has been used for paracentesis should not be reported separately, as these form part of the procedure and should only be reported with 49083.

"A common reason to need imaging is when the patient has pockets of fluid separated by cancerous masses or partially distended bowel," says Weinstein. "In these patients, the physician will want to avoid placing a needle into a mass or bowel loop and can better define the proper location for paracentesis using sonography to locate accessible pockets of intra-abdominal fluid."

So, if your gastroenterologist is performing an abdominal paracentesis with the use of imaging guidance, you should only report 49083 and not use 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation), 77002 (Fluoroscopic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]), 77012 (Computed tomography guidance for needle placement [eg, biopsy, aspiration, injection, localization device], radiological supervision and interpretation) or 77021 (Magnetic resonance guidance for needle placement [eg, for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation) to report the imaging guidance.