Gastroenterology Coding Alert

Question: The gastroenterologist performed peritoneocentesis on a patient to drain fluid from his abdominal cavity. The sessions were two days apart, but I'm curious about how to report the encounters. Can we code for both the initial and subsequent peritoneocentesis on the claim?

California Subscriber

Answer: Yes, you can. When you file the claim, you should:

• report 49080 (Peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; initial) for the first session.

• report 49081 (... subsequent) for the second session.

Heads-up: Physicians often perform peritoneocentesis (also known as abdominal paracentesis or peritoneal lavage) over several sessions. CMS prohibits reporting both codes on the same date, but if you report 49080 and 49081 on different dates of service, the insurer should not bundle the codes.

Also, when your gastro performs peritoneocentesis with imaging guidance, you may be able to report these codes:

Note: Check with the individual payer for its imaging guidance policy before filing a peritoneocentesis claim with 76360 and/or 76942 included.