General Surgery Coding Alert

If you follow a few simple rules, you-ll find that reporting thoracoscopy procedures is a cinch. Let our experts share with you the facts you need to guarantee success on every thoracoscopy claim.

If the surgeon performs a diagnostic thoracoscopy (32601-32606) and, as a direct result of her findings, determines the need for an open surgical procedure, you may report the diagnostic thoracoscopy separately. CMS guidelines, as outlined in the national Correct Coding Initiative (CCI), specifically state that if the surgeon performs an endoscopy for an initial diagnosis on the same day as the open procedure, you may report the endoscopy separately.

Apply a modifier: For Medicare payers, you should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the open procedure to indicate that the diagnostic endoscopy and the open surgical service are staged or planned procedures, according to instructions in CCI's introduction (section C, #12). In addition, "the medical record must document the medical reasonableness and necessity for the diagnostic endoscopy," CCI says.

Example: The surgeon uses diagnostic thoracoscopy to examine a patient with pain and breathing difficulty (32601, Thoracoscopy, diagnostic [separate procedure]; lungs and pleural space, without biopsy). The surgeon identifies and locates a foreign body in the pleural space, and removes the object via thoracotomy (32150, Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit).

In this case, because the scope determined the need for the thoracotomy, you should claim both 32601 and 32150-58.

Don't overdo it: If the surgeon uses a diagnostic scope to "scout" the surgical field -- to establish anatomic landmarks or to discern the extent of disease -- you cannot report the diagnostic scope separately, says M. Trayser Dunaway, MD, a surgeon, speaker, coding educator and healthcare consultant in Camden, S.C. Rather, the diagnostic scope must lead directly to the decision to perform surgery.

When the surgeon performs a diagnostic thoracoscopy followed by a surgical thoracoscopy (32650-32665), you may report only the surgical thoracoscopy, regardless of whether the results of the diagnostic scope prompted the surgical scope, says Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C. As CPT instructions clearly state, "Surgical thoracoscopy always includes diagnostic thoracoscopy."

Example: Returning to the above instance of foreign-body removal from the pleural space: If, instead of thoracotomy, the surgeon removes the object via thoracoscopy (e.g., 32653, Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit), you would not report the diagnostic thoracoscopy (32601) separately. Rather, because surgical scope always includes diagnostic scope, you would report the surgical scope (32653) only.

When the surgeon performs multiple surgical thoracoscopies at different sites during the same operative session, you may report each scope separately.

Example: For a patient with repeated pneumothorax, the surgeon uses the thorascope to induce adhesion (32650, Thoracoscopy, surgical; with pleurodesis). At the same time, he performs a segmentectomy (32663, ... with lobectomy, total or segmental).

You should report 32663, followed by 32650. The payer may impose a multiple-procedure payment reduction on the second (and any subsequent) scope.

Remember, also, that you should report only the successful procedure when the surgeon must convert an endoscopic procedure (such as a thoracoscopy) into an open procedure (such as a thoracotomy), according to CMS/CCI guidelines.

Example: Consider once more the case in which the surgeon attempts to remove a foreign body in the pleural cavity. The surgeon begins by attempting to use the thorascope (32653), but due to difficulties, she must abandon the scope and remove the foreign body via thoracotomy (32150).

Here, report only the open procedure (32150).

Finally: You should not report 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]) in addition to thoracoscopy procedures 32601-32665, Dunaway says.

For the surgeon to perform thoracoscopy, the pleural space between the lung and chest wall must be large enough so that he can move the instruments around easily and visualize all areas of the thoracic cavity.-The surgeon must create a pneumothorax (32422) to provide this space. Therefore, CMS considers 32422 to be an integral component of thoracoscopy.