Pinpoint the Correct Pleural Effusion Code
Question: A 56-year-old patient presented to the pulmonologist for a pleural effusion evaluation. The patient reported progressive shortness of breath and chest discomfort on the right side; both conditions have developed over the previous three weeks. The patient’s primary care physician (PCP) identified right-sided pleural effusion on chest X-rays. After reviewing the patient’s history and performing a physical examination, the pulmonologist performed an ultrasound-guided thoracentesis of the right hemithorax. The physician aspirated approximately 750 mL of clear yellow pleural fluid. The provider’s assessment lists right-sided pleural effusion, and that they are awaiting pleural fluid analysis results to determine etiology. How would I code this encounter? Kentucky Subscriber Answer: Assign 32555 (Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) to report the thoracentesis with ultrasound guidance. This code includes the imaging guidance, so you won’t report that portion separately. Pleural effusion is the most appropriate diagnosis you can proceed with until the pulmonologist receives the pathology report confirming the cause of the pleural effusion. In the Alphabetic Index of the ICD-10-CM code set, search for Pleurisy > with > effusion, which refers to J90 (Pleural effusion, not elsewhere classified). Verify the code in the Tabular List. Code J90 also lists pleural effusion not otherwise specified (NOS) as an alternative diagnosis. This matches what you’ve presented in your question. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
