Pulmonology Coding Alert

Tip: Syringe and catheter play important roles.

Thoracentesis helps to diagnose or to treat a patient with a pleural effusion. If you're not careful about identifying the procedure and equipment, you could easily get confused between the two codes for thoracentesis. In fact, reporting 32421 instead of 32422 could spell a difference of about $38 per procedure. There are clues in the thoracentesis report that will point you to the appropriate thoracentesis code, particularly within what actions the pulmonologist take and what type of equipment is used. Look for these clues to submit your claims minus the headache.

Take Syringe Use as a Hint for 32421

Scenario 1: A patient comes to the office complaining of shortness of breath. The pulmonologist evaluates the patient obtaining important historical information. She then performs an exam, including percussion and auscultation of the lungs. She percusses the patient's chest, noting dullness. The breath sounds are greatly diminished over the area where the dullness was found. After a chest x-ray, she confirms the presence of a pleural effusion.

Based on the x-ray results, the pulmonologist decides to sample the patient's pleural effusion using a needle attached to a syringe. He then sends the fluid to the laboratory for analysis.

The results indicate the presence of an exudative pleural effusion. What should you report?

Solution 1: The pulmonologist has performed a 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.

The only way a pulmonologist can determine the cause of pleural effusion is through a laboratory analysis of the fluid, according to Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. In some cases when a pulmonologist needs a small sample of pleural fluid for analysis, the pulmonologist will perform a thoracentesis by withdrawing fluid through a needle connected to a syringe to diagnose the patient's condition, says Pierre Edde, MD, head of the ulmonology/critical care/sleep division at Pennsylvania's Uniontown Hospital. You should report that service with 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent).

Next step: 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 due to pneumonia, malignancy, connective tissue diseases, etc.)

Tube Placement? Go for 32422

Scenario 2: A patient with malignant effusion due to lung cancer requires a thoracentesis to help relieve dyspnea. During the procedure, 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. What should you report?

Solution 2: The appropriate thoracentesis code for this scenario is 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]). Use 511.81 (Malignant pleural effusion), and 162.9 (Malignant neoplasm of, bronchus and lung; unspecified) to 32422 to report the patient's malignant effusion and cancer.

Remember: When a thoracentesis is performed using a small catheter inserted over or through a needle for diagnostic or therapeutic purposes, use 32422.

• Edde notes that there are different reasons a pulmonologist may perform therapeutic thoracentesis, such as:
• relieving symptoms (such as shortness of breath or pain);
• reversing atelectasis/collapse (a condition the effusion can cause, which could result in a pneumonia);
• improving oxygenation or pulmonary function/reserve (often caused by the atelectasis/collapse).

Physician Notes Give the Code Away

When you need to code for a thoracentesis claim, make sure you put the spotlight on the patient's medical record, which should describe clearly how the pulmonologist removed the fluid and what equipment he used. Otherwise, you risk losing out on your reimbursement, which cost about $156 for 32421, and $193 for 32422 (based on the 2010 Medicare Physician Fee Schedule, and the conversion factor [CF] of $36.0791).

Important: Two other separately reportable services -- aside from E/M service -- may be covered in thoracentesis. You may report the following services separately, as the need arises:

• 71020 -- Radiologic examination, chest, two views, frontal and lateral;
• 76942 -- Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

Example: A pulmonologist performs a diagnostic thoracentesis on a patient using a catheter with ultrasound guidance. You would report the following:

• 32422 for the thoracentesis;
• 76942 for the ultrasound guidance; modifier 26 (Professional component) appended to 76942 to indicate that you are billing only the code's professional portion when performing these services in facilitybased settings.
• 511.9 (Unspecified pleural effusion)

Exception: The rule of thumb is that only one provider can report a chest x-ray. In most facility-based settings, the radiologist will provide the formal report of interpretation, and thus bill for the chest x-ray service. This prohibits the pulmonologist from billing any component of 71020.