Pulmonology Coding Alert

Question: Our physician recently treated a patient who had a pleural effusion. The physician performed drainage for the accumulated fluid and also a pleural biopsy at the same time. How do we code for both the pleural biopsy and the drainage of the pleural fluid?  

Mississippi Subscriber

Answer: You have not provided the details of the drainage method used by your physician. There are two methods of pleural drainage. The provider inserts a hollow needle into the pleural space. Sometimes radiological guidance is also used. The physician then uses the needle to remove fluid from the pleural space. Typically, thoracentesis with catheter insertion is a one–time, in and out, event. When patients have large effusions, the surgeon may secure the catheter may leave it in the pleural space overnight for repeat drainage the next day. Once the fluid is drained, the physician removes the needle and bandages the site. For this type of drainage, also known as pleural tap, you can report 32554 (Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance) for thoracentesis or 32556 (Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance) for pleural drainage with insertion of an indwelling catheter.

Note that this is not the same as a chest tube insertion where the chest tube is left in place for several days for drainage. In that procedure, the provider uses a trocar to make an incision on the chest wall near the fifth intercostal space and enters the pleural cavity. The provider then inserts a hollow plastic tube between the ribs and into the chest to draw out fluid or air from and around the lungs. The provider sutures the skin to keep the tube in place. The provider may attach the free end to an underwater seal, which allows drainage of fluid and air from the chest. For such a procedure, you should report 32551 (Tube thoracostomy, includes connection to drainage system [e.g., water seal], when performed, open [separate procedure]).

You can report pleural biopsy with code 32400 (Biopsy, pleura; percutaneous needle). Based on which code you select from above, there is a bundled relationship between 32400 and 32554 (32554 is comprehensive code to 32400) and between 32400 and 32556 (32556 is a component of 32400). If the drainage is performed at a session that is separate and distinct from the pleural biopsy, you can attach modifier 59 (Distinct procedural service) to the CPT^® code identifying the appropriate drainage procedure, along with its separate and distinct ICD-9 code. This may allow for separate reimbursement of the pleural biopsy, if appropriate.

Append ICD-9 code 511.81 (Malignant pleural effusion) and 162.9 (Malignant neoplasm of bronchus and lung, unspecified) to 32422 to report the patient’s malignant effusion and cancer. Under ICD-10 system, you will report the same with J91.0 (Malignant pleural effusion). Code 162.9 will get more specific with either C34.90 (Malignant neoplasm of unspecified part of bronchus or lung), C34.91 (Malignant neoplasm of unspecified part of right bronchus or lung) or C34.92 (Malignant neoplasm of unspecified part of left bronchus or lung).