Gastroenterology Coding Alert

Question: The gastroenterologist performed paracentesis on a patient to drain fluid from his abdominal cavity in two sessions that were two days apart. How should we report the encounters? Can we code for both the initial and subsequent paracentesis on the claim?

Texas Subscriber

Answer: You should report the two sessions separately as according to your description, the first session was for the paracentesis and the second for draining the excess fluid. In neither case do you mention imaging guidance. You should report the first session with CPT® code 49082 (Abdominal paracentesis [diagnostic or therapeutic]; without imaging guidance). If your gastroenterologist used imaging guidance for paracentesis, you should then bill code 49083 (Abdominal paracentesis [diagnostic or therapeutic]; with imaging guidance) instead of 49082. 

You should report the second session with 49082 in the case of a repeat paracentesis.. Please go through your physician’s notes to determine if he performed a lavage in the subsequent session. In that case you would report 49084 (Peritoneal lavage, including imaging guidance, when performed) for the second session. 

All modality-specific image-guidance is included with 49083 and 49084, unless a catheter is left in place for follow-up paracentesis, which would then be described by 75989 (Radiological guidance [ie, fluoroscopy, ultrasound, or computed tomography], for percutaneous drainage [eg, abscess, specimen collection], with placement of catheter, radiological supervision and interpretation). Follow-up paracentesis through a previously placed catheter would be reported with an evaluation and management code, since the catheter placement has already been coded. Report code 49082 only if a new catheter is placed through a new access, on a different date of service.

There are several conditions which can cause ascites (fluid) to accumulate in the abdominal cavity including cirrhosis, metastatic cancers, infection, or ruptured cysts.  To determine the cause of the fluid accumulation it may be necessary to remove a small amount of the fluid for analysis during a diagnostic paracentesis. Depending on the condition causing the fluid, your physician may also decide to remove as much of the fluid as possible during a therapeutic paracentesis. In 2012, CPT® removed codes 49080 and 49081 which were separate codes for “initial paracentesis” and “subsequent paracentesis.” The new codes for abdominal paracentesis, 49082 and 49083, describe the procedure performed without or with imaging guidance. Code 49084, Peritoneal lavage, including imaging guidance, when performed is used to describe a more invasive procedure that includes a skin incision.

Heads-up: 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. In some cases, it may be necessary to administer intravenous fluids to replace volume removed during a therapeutic paracentesis.

Caution: According to CPT®, you cannot report any of the following codes with 49083 for use of imaging guidance for paracentesis: 

• 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 interpretatio

• 77021 – Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation.