General Surgery Coding Alert

Question: We have an op note in which the surgeon drained pleural fluid and performed a needle pleural biopsy in the same session. Should we code the drainage service as 32554, and can we add a biopsy code?

Texas Subscriber

Answer: Without the details from the op note, it’s difficult to know how to code the drainage. 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).

Biopsy: Unless the surgeon documents a separate, distinct needle biopsy service, you should not additionally report 32400 (Biopsy, pleura, percutaneous needle). 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 other 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).