Pulmonology Coding Alert

Question: Two weeks post lung transplant, a hospital inpatient has a high fever and elevated blood pressure, slightly reduced urine output, and moderate chest pain when he breathes. A pulmonologist examines the patient and orders and reviews the results of a chest radiography and multiple blood tests. Because the chest radiograph shows pleural effusion, the physician performs a thoracentesis after ultrasound evaluation of the pleural space. How should we code the scenario?

Maine Subscriber Answer: You'll reduce the chance of a denial for an E/M service that results in a thoracentesis and avoid overlooking ethical coding opportunities if you follow this agenda:
 
Step 1: If documentation supports a level-three hospital care service, you should report 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...). Based on the information provided, the scenario involves two of the three components necessary for choosing that E/M level:

 • a detailed history
 
• high-complexity medical decision-making. Step 2: Append the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). You need the modifier to designate 99233 as a significant, separately identifiable service from the thoracentesis. Code 99233 includes the work associated with the examination and the review of the blood test that resulted in the plan for thoracentesis.
 
Step 3: If the pulmonologist interpreted the ultrasound results and prepared the report, you should report 76604 (Ultrasound, chest [includes mediastinum], real time with image documentation) appended with modifier 26 (Professional component). The hospital will report the blood tests and the technical components (modifier TC) of the ultrasound because it provided the staff and facilities for the procedures. Remember: Do not report radiological service codes when the physician uses hand-held devices not capable of storing data or providing a copy of images.
 
Step 4: You should use 32000 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for the thoracentesis. Do not use a modifier on 32000. If the pulmonologist placed a plastic catheter in the pleural space to drain the fluid during the thoracentesis, use 32002 without a modifier.
 
Step 5: Link both 99233-25 and 32000 or 32002 to pleural effusion (511.9). Because the specific diagnosis that caused the effusion is yet to be determined pending laboratory testing of the fluid, you should use the effusion as the diagnosis for that day's service and procedure.