Gastroenterology Coding Alert

Question: A 52-year-old female presented with worsening abdominal distension and a 15-pound weight gain during the past month. She has a known history of ovarian cancer that was unsuccessfully resected a few months earlier. The increasing distension has made breathing difficult. The gastroenterologist reviewed the prior records and performed an abdominal sonogram, confirming the presence of ascites. He also decided to perform a large volume paracentesis (removal of abdominal fluid, 49080) to provide the patient some relief from her discomfort. How should I report this encounter?

New Mexico Subscriber

Answer: In this case, you can report three CPT codes.

First, you should use the appropriate E/M code -- such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) -- to report the evaluation and decisions to perform the sonogram and then the paracentesis.

Next, report the limited abdominal sonogram with 76705 (Ultrasound, abdominal; real time with image documentation; limited [eg, single organ, quadrant, followup]).

You would also report the paracentesis procedure separately using code 49080 (Peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; initial).

Don't miss: Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show that the service was separate from the actual performance of the paracentesis procedure. The documentation should show a separate note for the E/M visit, a report of the limited abdominal sonogram, and a paracentesis procedure note.

The diagnosis codes should be ranked by your physician in his progress note since you will have over four appropriate diagnosis codes to report. Here are some of the appropriate diagnosis codes to report for the visit:

183.0 -- Ovarian cancer

789.07 -- Abdominal pain; generalized

786.05 -- Shortness of breath

789.51 -- Malignant ascites

783.1 -- Abnormal weight gain.