Pulmonology Coding Alert

Patients who develop pleural effusions often require a thoracentesis to diagnose or treat the condition. If you fail to identify the procedure and equipment, you could end up selecting 32421, rather than 32422 -- a difference of about $38 per procedure.

Look for these clues to submit your thoracentesis claims correctly.

For some patients with a pleural effusion, the pulmonologist will need to obtain a small sample of pleural fluid for analysis. "The physician may be able to determine the cause of the pleural effusion after lab analysis of the fluid," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

When the pulmonologist performs a thoracentesis by withdrawing fluid through a needle connected to a syringe to diagnose the patient's condition, you'll report the service with 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent), says Pierre Edde, MD, head of the pulmonology/critical care/sleep division at Pennsylvania's Uniontown Hospital.

"The physician performs the procedure to obtain a sample of fluid to make the diagnosis," Edde says. The physician will send the patient's sample to the laboratory, which will determine whether the fluid is transudative (usually due to increased hydrostatic pressure from cardiac, liver or renal failure) or exudative (usually from pleural involvement from pneumonia, malignancy, connective tissue diseases, etc.).

Example: An established patient with shortness of breath reports to the office. The pulmonologist obtains pertinent historical information and performs an exam, including auscultation of the lungs, which sound muffled. He then taps on the patient's chest and notes a dull "thud." A chest x-ray confirms the presence of a pleural effusion.

Office notes substantiate a level-four E/M. Based on the evaluation, the pulmonologist decides to perform a diagnostic thoracentesis. After the patient is prepped, pleural fluid is withdrawn through a needle into a syringe and sent to the laboratory for analysis. The results indicate the presence of an exudative pleural effusion.

This is an example of diagnostic thoracentesis. On the claim, you should report the following:

• 32421 for the thoracentesis

• 511.9 (Unspecified pleural effusion) linked to 32421 to represent the pleural effusion

• 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M

• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99214 to show that the E/M and thoracentesis are separate services

• 786.05 (Shortness of breath) linked to 99214 to represent the patient's breathing difficulty.

• 71020 (Radiologic examination, chest, two views, frontal and lateral) for the x-ray

• 511.9 linked to 71020 to represent the effusion.

When the pulmonologist performs a thoracentesis using a small catheter inserted over or through a needle for diagnostic or therapeutic purposes, you'll code the service with 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]), Edde says.

According to Edde, the pulmonologist may perform a therapeutic thoracentesis to:

• relieve symptoms (such as shortness of breath or pain)

• reverse atelectasis/collapse (a condition the effusion can cause, which can result in pneumonia)

• improve oxygenation or pulmonary function/reserve (often caused by the atelectasis/collapse).

Example: A patient with a malignant effusion due to lung cancer requires a thoracentesis to help relieve dyspnea. During the procedure, the physician uses a thoracentesis kit containing a catheter over a needle to withdraw the maximum amount of pleural fluid.

In this instance, report 32422 for the thoracentesis. Link 511.9 (Unspecified pleural effusion) and 162.9 (Malignant neoplasm of trachea, bronchus and lung; unspecified) to 32422 to represent the patient's malignant effusion and cancer.

For patients who receive a thoracentesis, the medical record should describe clearly how the pulmonologist removed the fluid and which equipment he used. This information will help you choose the correct code.

In short: If the pulmonologist uses a syringe and needle during the procedure, but does not insert a catheter, it is a 32421 service, Edde says. If the pulmonologist inserts a catheter in the pleural cavity, the encounter is a 32422 service.

Code 32421 example: The pulmonologist inserts a needle in the patient's pleural cavity and obtains a syringe full of fluid, which he sends to the laboratory for analysis.

Code 32422 example: The pulmonologist inserts a catheter over a needle into the pleural cavity, withdraws the needle, and drains the pleural fluid. The catheter remains in place until the procedure is over when the physician removes it.

Reimbursement: The average amount you'll receive for 32422 is $204.15 (5.36 RVUs x 38.0870 Medicare conversion rate). The 32421 code averages about $165.68 (4.35 RVUs x 38.0870).

In addition to a possible E/M service, be on the lookout for two other separately reportable services. According to Pohlig, you may be able to report these procedures separately when the physician performs them during thoracentesis:

Exception: Only one provider can report a chest x-ray. Therefore, in most facility settings, the radiologist will provide the formal report of interpretation and code for the chest x-ray. This precludes the pulmonologist from billing for the service.

Example: The pulmonologist meets a patient at the hospital. He performs diagnostic thoracentesis using a catheter with ultrasound guidance. On the claim, report the following:

• 32422 for the thoracentesis

• 76942 for the ultrasound guidance

• modifier 26 (Professional component) appended to 76942 to show that you are billing only the code's professional portion.