Pulmonology Coding Alert

Question: I have a report that states the pulmonologist performed a thoracentesis procedure and removed fluid from the pleural space for a patient suffering from pleural effusion. The report also states “US guidance.” Does that mean the provider used imaging guidance for the procedure?

Texas Subscriber

Answer: Yes, “US guidance” is an abbreviated way of describing ultrasound guidance. You’ll want to choose an appropriate thoracentesis code that includes imaging guidance to report the procedure. In your case, you’ll assign 32555 (Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) to report the pulmonologist’s procedure.

During thoracentesis, the provider inserts a thin needle or catheter into the space between the chest and lungs to remove excess fluid from the pleural space. Providers use imaging guidance to ensure the needle is in the correct position. Ultrasound, fluoroscopy, or computed tomography (CT) guidance are typically used for the imaging guidance.

Additionally, unless the pulmonologist documented detailed information regarding the pleural effusion, you’ll assign J90 (Pleural effusion, not elsewhere classified) to report the medical necessity for the procedure. Code J90 features pleural effusion not otherwise specified (NOS) as an additional condition that is covered by the diagnosis code.