Pulmonology Coding Alert

Hint: Imaging guidance is the final key to precise code selection.

To accurately report the new CPT^® 2013 codes for thoracentesis and pleural drainage, you’ll need to focus on factors such as imaging guidance, procedural purpose, and the equipment used.

Base Right Thoracentesis or Pleural Drainage Code Selection on Imaging

When your pulmonologist performs thoracentesis or pleural drainage, your final code selection will depend on imaging guidance he used. To appropriately report based on imaging guidance, you’d choose one of the following two codes for thoracentesis, depending on the procedure documentation:

·         32554 — Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance

             32555 — …with imaging guidance

Similarly, you have two codes for pleural drainage, depending whether or not imaging guidance is documented:

·         32556 — Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance

             32557 — …with imaging guidance

Check Intent to Discern Between Thoracentesis and Pleural Drainage

You can avoid coding confusion between thoracentesis and pleural drainage if you look at why your pulmonologist performed the procedure. “A thoracentesis is the insertion of a needle or a needle with a catheter into a pleural effusion,” says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. “Whoever performs the procedure should write in the chart that a thoracentesis was performed, what was the characteristics of the fluid (color, cloudiness, odor, etc.), how much was removed and what tests will be performed on the fluid. Any complications should be noted as well.” If your pulmonologist only removed some fluid collected in the pleural space for analysis, then you will have to choose the appropriate thoracentesis code based on usage of imaging guidance.

But if your pulmonologist placed an indwelling catheter to drain out fluid or air accumulated in the chest wall, you will have to select the appropriate pleural drainage CPT^® code taking into consideration the use of imaging guidance. “The term ‘pleural drainage’ is a misnomer conjured up by the CPT^® Editorial Panel,” says Plummer. “This is really the percutaneous insertion of a chest tube by any method except an open, surgical method (reported by 32551).  The chest tube is left in the chest and is attached to a drainage system.  The chest tube insertion should be documented in the chart.”

Example: A 63-year-old male patient presents to your pulmonologist’s office with complaints of severe cough and shortness of breath. He also complains of intermittent fever for the past few days, although the temperature recorded presently is near normal. Upon auscultation, your pulmonologist notes dull breath sounds and dull percussion note.

Your pulmonologist then orders a chest x-ray. Upon visualizing the x-ray, your pulmonologist notes the presence of fluid in the pleural space and proceeds to perform a thoracentesis by inserting a needle using ultrasound guidance. The aspirated fluid is then sent to the laboratory for analysis. You will need to choose 32555 as your pulmonologist performed a thoracentesis using imaging guidance.

Use Same Code Sets for Thoracentesis Equipment

One source of coding confusion with the earlier code sets for thoracentesis was discerning the right code depending on whether a needle or a catheter was used to conduct the procedure.

“The new codes, 32554 and 32555 have eliminated this problem, as you will use the same set of codes irrespective of what equipment was used to conduct the procedure,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia. “The descriptors to these codes prompt the same code selection irrespective of catheter or needle usage when conducting the procedure.”

Result: So, you will report your code based on imaging guidance and will not need to worry about whether a catheter was used or if your pulmonologist inserted a needle to aspirate the fluid from the pleural space.

Don’t Report Indwelling Catheter Placement Separately

When your pulmonologist places an indwelling catheter to drain the fluid accumulated in the pleural space, you might wonder if you need to report placement of the indwelling catheter separately. Even though there is a separate code to report placement of an indwelling catheter (32550, Insertion of indwelling tunneled pleural catheter with cuff), you cannot report it separately if your pulmonologist performs pleural drainage in the same session during which he placed the catheter.

If you look at the descriptor to 32556 and 32557, you will note that these CPT^® codes include temporary placement of the indwelling catheter. If your pulmonologist performs insertion of a tunneled catheter without performing any drainage, report 32550 instead. 

Example: A 72-year-old male with a known history of lung cancer is seen by your pulmonologist for increasing dyspnea. Chest X ray reveals a large left pleural effusion. Your pulmonologist places an indwelling catheter temporarily and drains the pleural effusion and the patient becomes more comfortable. He did not use any imaging guidance for placement of the catheter. You will report the procedure with 32556.