Pulmonology Coding Alert

Watch for scenarios needing bilateral claims.

Whenever your pulmonologist removes fluid from the pleural space, you need to focus on the amount of fluid removed, the use of imaging guidance during the procedure and whether or not the procedure was repeated bilaterally.

Case Scenario 1: Your pulmonologist evaluates a 52-year-old established male patient with complaints of persistent cough with sputum for the past three weeks. The patient complained that he also has started developing chest pain on the right side and increasing dyspnea from the past two to three days. The patient has a history of smoking cigarettes for the past two decades.

Upon clinical examination, your pulmonologist observes the presence of dullness on percussion and reduced breath sounds. The chest x-ray that your clinician orders confirms the presence of fluid collection in the pleural space on both sides. Your pulmonologist inserts a needle and aspirates the fluid from the pleural space and sends it to the lab for analysis. The procedure is repeated on the left side. No imaging guidance is used for the procedure.

Case Scenario 2: Your pulmonologist evaluates a 50-year-old established male patient with complaints of cough with sputum for the past three weeks. The patient also complains that he has been increasingly having chest pain over the right side and shortness of breath from the past week or so. The patient has a previous history of pneumonia that was treated about five years ago.

Upon clinical examination, your pulmonologist observes the presence of dullness on percussion and reduced breath sounds over the right side of the chest. The chest x-ray that your clinician orders confirms the presence of a large pleural effusion on the right side. Your clinician then proceeds to place a catheter and drains the fluid from the pleural space. Your clinician uses ultrasound guidance for placement of the catheter prior to draining.

Both of these case scenarios sound similar. So, should a thoracentesis code or a pleural drainage code be used to report for these procedures? Should bilateral procedures be reported separately?

Ask yourself the following questions to help you arrive at the right code(s) so you can report the procedures and the evaluation that your pulmonologist performed prior to the procedure.

# 1 Was it a Thoracentesis or Pleural Drainage?

Whenever your clinician drains fluid from the pleural space, you will need to first ascertain whether he performed a thoracentesis or pleural drainage. You can get an answer to this query if you look at the amount of fluid that your clinician removed during the procedure.

If your pulmonologist only aspirated a small amount of fluid that he sent to the lab for analysis, you will have to report the procedure using one of the thoracentesis codes. If the accumulated fluid was drained by catheter placement, then you will have to choose pleural drainage procedural codes.

In case scenario 1, since your clinician aspirated a small amount of fluid and sent it to the lab for analysis, you should report thoracentesis codes for this procedure. In case scenario 2, your pulmonologist introduced an indwelling catheter and drained the effusion. Therefore, you will have to report pleural drainage procedural codes for this example.

Note: Don’t go by placement of catheters to decide whether you will have to report pleural drainage procedural codes. Your clinician will perform a thoracentesis procedure either by placement of needles or using a catheter to aspirate fluid from the pleural space. Instead, rely on your clinician’s documentation to check the amount of fluid removed from the pleural space to arrive at the appropriate procedural code. If in doubt, query your clinician to avoid the risk of denial.

#2 Did the Procedure Involve Imaging Guidance?

Once you have determined whether your clinician performed a thoracentesis or a pleural drainage, the next question that you will have to ask yourself is if your pulmonologist used imaging guidance during the procedure. There are two codes for you to select for each procedure depending on whether or not your clinician used imaging guidance.

The CPT® codes that you will report for a thoracentesis procedure based on use of imaging guidance include:

• 32554 -- Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance
• 32555 -- …with imaging guidance

Again, the two code choices based on imaging guidance for a pleural drainage include:

• 32556 -- Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance
• 32557 -- …with imaging guidance

In case scenario 1, since your clinician placed the needle for aspiration of the pleural fluid without the use of any imaging guidance, you will report 32554 for the procedure. Your pulmonologist used imaging guidance for the placement of the catheter in case scenario 2. Therefore, you will need to report 32557 for this procedure.

#3 Should Placement of Catheter Be Reported Separately?

For drainage of the pleural fluid, your clinician will place a catheter. Since there is a separate code for the placement of a catheter, you might be asking yourself if you need to report this separately with 32550 (Insertion of indwelling tunneled pleural catheter with cuff). The answer to this question is ‘No.’

If you look at the descriptors to pleural drainage codes, you will notice that they include the term “with insertion of indwelling catheter.” Since the codes include this terminology, you will not have to report placement of the catheter separately.

Caveat: “32550 represents the placement of a tunneled pleural catheter, typically used for more frequent and ongoing drainage related to recurring accumulation of pleural fluid,” says Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. “It is not used for conditions requiring only temporary catheter placement.”

#4 Should Bilateral Procedures Be Reported Separately?

The next question that you need to ask yourself is whether you have to report bilateral procedures with a separate unit of the code, use a modifier, or just report one unit of the code. In case scenario 1, your clinician repeated the thoracentesis on the other side.

If your clinician repeats the thoracentesis or the pleural drainage procedure bilaterally, you will have to report the repeat procedure on the other side separately, and the method will depend on payer preference. You will have to choose from modifier 50 (Bilateral procedure), 59 (Distinct procedural service) or RT (Right side [used to identify procedures performed on the right side of the body])/LT (Left side [used to identify procedures performed on the left side of the body]), depending on the payer’s preference and recognition of certain modifiers.

Modifier 50 requires a single line item CPT® code with a unit of “1.” The other modifiers require two line items: 32554, 32554-59; or 32554-RT and 32554-LT. When supported with correct documentation, you may receive up to 150 percent of the Medicare allowable rate: 100 percent for the first procedure and 50 percent for the second.

So, in case scenario 1, you will need to report the repeat procedure separately using the above mentioned appropriate modifiers depending on payer preference.