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Question: Our surgeon wrote an op note in which they drained pleural fluid and performed a needle pleural biopsy during the same operative session. Are we able to code the drainage service as 32554, and add a biopsy code as well?

Minnesota Subscriber

Answer: It’s difficult to know how to code the drainage without more details from the surgeon’s note. If the surgeon uses a needle or catheter to remove some fluid from the pleural space, typically for therapeutic or diagnostic purposes, the appropriate code would be 32554 (Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance).

On the other hand, if the surgeon percutaneously inserted an indwelling catheter (chest tube) to drain the pleural fluid, you should report 32556 (Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance).

Regarding the biopsy portion— if the surgeon doesn’t record a separate and distinct needle biopsy procedure, then the code 32400 (Biopsy, pleura, percutaneous needle) should not be reported additionally. The surgeon would typically use aspirate from the thoracentesis or drained fluid to submit as a biopsy for pathologic evaluation. If the op note shows a separate procedure that warrants billing 32400, you should use modifier 59 (Distinct procedural service) or another appropriate modifier such as XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC