Pulmonology Coding Alert

Needle or catheter guide your code selection

You'll find reporting thoracentesis an arduous task as there are two different codes for this procedure. To make it easier, you should always follow what procedure was done and not the cause of the effusion. Follow these simple rules for accurate code selection -- and rightful reimbursement.

Refresh Your Procedure Knowledge

Thoracentesis, also called thoracocentesis or pleural tap, is a procedure done under local anesthesia to remove fluid or air present in the pleural space. Fluid may collect in the pleural space due to conditions like pneumonia, congestive heart failure, recent surgical procedure, cancer, or tuberculosis. The removal of the fluid could be done either for diagnosis of the condition that has caused it or for therapeutic reasons to relieve the discomfort of the patient. The removal of the fluid improves the lung function.

Watch Overuse of 32421

The clinical note may specify that the physician drained and sent fluid that had been removed to the laboratory. Your pulmonologist may have established the specific diagnosis of 'pleural effusion' after the procedure. In this situation, you may mistakenly assume that you should report code 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent). Keep in mind that the procedure may not have been that simple, and you will have to look further into the details of the report to see which method was employed.

If the report mentions that the patient has a pneumothorax, it is likely that this was resolved with the catheter method (see below). Thoracentesis involving pneumothorax are reported with 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]). This was done to help in providing relief from the symptoms that are stressing to the patient, then the procedure is said to have a therapeutic intent. Some instances where such an intervention will be initiated include dyspnea (shortness of breath) experienced by a patient with lung cancer and in patients with atelectasis (lung collapse).

Note: Your pulmonologist usually sends the removed fluid to the laboratory to check if the fluid is exudative or transudative to know why the fluid has accumulated. The biochemical analysis of the fluid in laboratory conditions helps to establish the nature of the pleural fluid. This will also help in analyzing the reason for the pleural effusion (e.g., inflammation, organ failure, etc) and will aid in further establishing the diagnosis and treatment for the condition. Thoracentesis and insertion of a drainage tube usually suffice for the diagnosis and management of a pleural effusion in an emergency department.

Check for Needle or Catheter Technique

Another important tool in providing the right code for thoracentesis is to check the equipment used to drain the fluid from the pleural space. "This can be accomplished by a needle, a through-the-needle-catheter, or an over-the-needle catheter," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

"Overall, the catheter techniques may be safer," says Pohlig. "Fluid or air is withdrawn. Fluid is sent to the laboratory for analysis. If the air or fluid continues to accumulate, a tube is left in place and attached to a one-way system so that it can drain without sucking air into the chest."

If your pulmonologist is using a needle to withdraw the fluid, then the right code to go for is 32421 as the procedure is diagnostic. On the other hand, if the equipment mentioned for the removal of fluid is a catheter, then the right code that you need to go in for is 32422 as the catheter is used to remove the fluid in relieving the symptoms the patient is experiencing.

Example: Here's a procedure scenario to further illustrate catheter-based fluid removal: "After preparation of the necessary pleural tap kit, the patient was re-examined and auscultated to reconfirm the borders of the effusion. The patient was comfortably seated in a chair and leaned over a support in front.

After percussion to identify the upper border, the tap site was identified two intercostal spaces below the upper border of the effusion. Going two inches below the scapular tip, the site of penetration was marked on the skin. The area was prepared by using betadine swab and cleaning the area away from the center in a spiral direction and the patient's back was draped. The catheter was then checked for sliding. The local anesthetic was loaded and using the left finger to stabilize the skin, the needle of the syringe loaded with the local anesthetic was penetrated at 90 degrees to the skin.

After making a small bleb, the anesthetic was injected while aspirating. The flexible catheter was prepared and the large needle was used to enter the pleural space. While keeping the needle steady and applying firm pressure, aspiration was begun while advancing. The vacuum bottle was connected and the fluid allowed to drain. About 1300 cc of pleural fluid was removed.

At the end of the procedure, the path to the bottle was closed by turning the stop cock lever to prevent air from entering the pleural space. The catheter was quickly withdrawn and pressure was applied to the site which was sealed with a gauge and dressing. The chest X-ray was ordered to rule out pneumothorax,' you confirm the use of a catheter and drainage of a significant amount of fluid to ease the patient's discomfort.

Coding advice: You would report code 32422 because of the use of the catheter for draining the fluid that is accumulated within the pleural space to help relieve the symptoms the patient was experiencing.

Exception: You may read further in the same procedure note that 'a sample of the withdrawn fluid was sent for the laboratory analysis.' Do not be confused. You report 32422 and not 32421. This is because your physician is using a catheter. The method of the thoracentesis matters more than the reason for performing the procedure. "The reason may give you a hint to the overall nature of the procedure, and provide the medical necessity for the service; but the method employed will provide you will a more accurate rationale for procedure code selection," says Pohlig.

Reserve Your Reimbursement

Just by following this simple tip of looking for the equipment used in the tapping or drainage of the pleural fluid, you can avoid the risk of losing reimbursement by selecting the incorrect code, or having to refund excessive payment for a lesser service.

Stay tuned: In the next issue of Pulmonology Coding Alert you'll learn the truth about reporting radiological assistance and E/M services with thoracocentesis.