Pulmonology Coding Alert

When coding thoracentesis, you should understand the reason for the procedures first, then assign the various diagnoses carefully to reduce the chance of denial. Pulmonologists perform thoracentesis to remove fluid from the pleural space for both diagnostic and therapeutic reasons (see box on page 85). The physician's notes should indicate his or her reasoning for the thoracentesis.

"The coder should use the physician's procedure notes when coding to ensure reporting of the correct diagnosis(s)," says Mary Mulholland, RN, BSN, CPC, a senior coding and education specialist for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "Inappropriate reporting of services may be misconstrued as intentional if the incorrectly reported procedure is reimbursed at a higher rate than the other procedure." During a diagnostic thoracentesis (32000*, Thora-centesis, puncture of pleural cavity for aspiration, initial or subsequent), the physician removes the pleural fluid and sends it for testing. Therapeutic thoracentesis (32002, Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]) occurs when the doctor removes the fluid to allow the patient to breathe more easily. Usually, the initial patient visit will focus on obtaining accurate medical information to help the pulmonologist decide if a thoracentesis is the most appropriate procedure. In this case, you should report the appropriate E/M code (99201-99233). The proper code depends on the location of the service, nature of the service performed and intent of the requesting physician (in transferring care of the pulmonary problem to the pulmonologist).

If the pulmonary physician performs the thoracentesis on the same day as the E/M service, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. The physician may also use chest x-rays or ultrasound to visualize the pleurae, says Charlie Strange, MD, FCCP, director of the medical intensive care unit at the Medical University of South Carolina in Charleston

Frequently, the pulmonologist evaluates the patient and then performs the thoracentesis procedure at a later date. When reporting the thoracentesis in this instance, you should bill 32000 along with the appropriate E/M code because 32000 is a "starred" procedure, meaning the code only includes the procedure and not any pre- or postoperative services. Also, you should append modifier -25 to the E/M code to show that it is separate from the thoracentesis. How Diagnoses Affect Coding The diagnosis should clearly reflect the medical necessity for the care given the patient. CPT does not require different diagnoses for the E/M service and the procedure. When it's appropriate, use the same diagnosis for both. But if the diagnosis is different for [...]