Pulmonology Coding Alert

Thoracentesis may be performed either for diagnosis or therapeutic purposes, and also may include related procedures in addition to evaluation and management (E/M). You should understand the reason for the procedures first, then document the various diagnoses carefully to eliminate chance of denial.

The two pleurae covering the lungs where they meet the inside of the chest wall help reduce friction during breathing, says Gregory Tino, MD, FACC, assistant professor of medicine at the University of Pennsylvania in Philadelphia. Fluid can get trapped between the visceral pleura (next to the lungs) and parietal pleura (next to the chest wall). When this happens we often order a thoracentesis to help with the diagnosis or treatment.

To perform a thoracentesis, the pulmonologist inserts a small needle between the patients ribs into the space between the two pleurae. He or she drains the fluid and usually sends the fluid to a laboratory for cultures and other diagnostic tests.

Sometimes disease, such as cancer, causes fluid to build up and the patient experiences shortness of breath or coughing. When this happens, we do a therapeutic thoracentesis, says Tino. In this case we are more interested in getting the fluid out, letting the lungs expand and helping the patient get relief.

Understanding the Thoracentesis Service Codes

The physicians notes indicate whether the thoracentesis is done for diagnostic reasons or therapeutic ones, says Cynthia Somma, CMM, CPC, office manager for Nassau Queens Pulmonary Associates, PC, a private practice group in New Hyde Park, N.Y. In a diagnostic thoracentesis (32000, thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent), fluid is removed and sent for testing. Therapeutic thoracentesis (32002, thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]) occurs when the main reason the fluid is removed is so the patient can breathe better.

Usually the initial patient visit will focus on obtaining accurate medical information to help us decide if a thoracentesis is the most appropriate procedure, says Mary Mulholland, RN, BSN, CPC, reimbursement analyst in the department of medicine at the University of Pennsylvania in Philadelphia. Code the initial evaluation and management (E/M) with the appropriate E/M code (99201-99233). The choice of codes depends on the location of the service, nature of the service performed, and the intent of the requesting physician (in transferring care of the pulmonary problem to the pulmonologist). If the pulmonologist performs the thoracentesis on the same day as the E/M service, be sure to append the -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

In many cases the physician evaluates the patient and then performs the thoracentesis procedure at a later date. When reporting the thoracentesis, bill only 32000 because pre- and post-procedure evaluation and care of the patient is included in this code.

How Diagnoses Affect Coding

The diagnosis should clearly reflect the medical necessity for the care given the patient. According to CPT, different diagnoses are not required for the E/M service and the procedure. When its appropriate, use the same diagnosis for both. But if the diagnosis truly is different for the E/M and the procedure, make sure the diagnoses are properly linked to the specific service codes.

The ICD-9 codes paint a picture for the carrier of the symptoms the patient demonstrated and why the physician was medically justified in initiating their plan of care, says Mulholland. A symptom such as painful respiration (786.52) may be the only diagnosis available during the initial visit, but after a thoracentesis, the physician determines that the patient has a pleural effusion (511.9). Use the effusion as the diagnosis for that days service.

Billing for Thoracentesis Follow-up

After completion of a thoracentesis, often the pulmonologist sees the patient to discuss the findings and further treatment plans. Report this encounter with the established patient visit under the established patient codes (99211-99215) or subsequent inpatient codes (99231-99233). The physician discusses the results of the thoracentesis with the patient and outlines a plan of care based on the findings, says Mulholland. The level of service reported is based on the amount of face-to-face time spent with the patient in an outpatient setting or the floor/unit time spent on an inpatient basis. The rule is that more than 50 percent of the visit must be spent in counseling and coordinating care.

Time is the controlling factor. The physicians documentation must specify the total duration of the visit and the amount of time spent in counseling the patient. Also describe the encounter. Include what was discussed, the results of the various tests, an explanation of the current situation and outline treatment recommendations.

Mulholland stresses that only the time spent in contact with the patient is billable. The effort the physician spends evaluating the results of the test and preparing for the follow-up visit may not be billed separately. These components are included in the decision-making part of the E/M codes. Thoracentesis, like many other pulmonary procedures, has a zero-day global period, says Somma. Also, the procedure is exempt from using modifier -51 (multiple procedures). If you add code -51, you will incur unnecessary payment reduction.

Coding for Related Procedures

Inserting the needle during the thoracentesis may introduce air into the pleural space. Therefore, the pulmonologist typically orders chest x-rays (71020, radiologic examination, chest, two views, frontal and lateral) after the procedure to check for pneumothorax and to look for any other abnormalities that may have been obscured by the fluid.

The professional component of these services is usually bundled into the procedure. When ultrasonic guidance is used, however, the pulmonologist may bill 76934 (ultrasonic guidance for thoracentesis or abdominal paracentesis, radiological supervision and interpretation), appending modifier -26 (professional component) if the procedure is performed in a facility setting.

An additional charge for the surgical tray (A4550, surgical trays) is allowed for thoracentesis if the service is performed in the pulmonologists office.