Radiology Coding Alert

"Computerized tomography (CT) guidance for abdominal paracentesis and thoracentesis is a topic often discussed among coders, largely because the currently recommended CPT Code doesnt appear to accurately describe the procedure.

Both procedures, according to Jeff Fulkerson, supervisor of radiology billing at the Emory Clinic in Atlanta, involve removing fluid or air from cavities within the body. Thoracentesis involves removing fluid from the pleural cavity around the lungs, while abdominal paracentesis is a similar process used to remove fluid build-up in the abdomen. Procedure codes include:

32000 thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent;

32002 thoracentesis with insertion of tube with or
without water seal (e.g., for pneumothorax) (separate procedure);

49080* peritoneocentesis, abdominal paracentesis,
or periotoneal lavage (diagnostic or therapeutic); initial; and

49081* peritoneocentesis, abdominal paracentesis,
or periotoneal lavage (diagnostic or therapeutic); subsequent.

Fulkerson notes that CPT currently directs coders to use one of three guidance codes for these procedures:

76003 fluoroscopic localization for needle biopsy
or fine needle aspiration;

76360 computerized tomography guidance for
needle biopsy, radiological supervision and Interpretation; and

76934 ultrasonic guidance for thoracentesis or
abdominal paracentesis, radiological supervision and interpretation.

CT Guidance Code Doesnt Match Procedure

Although 76003 and 76934 unmistakably describe the fluoroscopy and ultrasound guidance involved, respectively, coders have often questioned the CT code, 76360. Its not 100 percent clear, says Lisa Grimes, RT (R), radiology special procedures technologist and reimbursement specialist for the University of Texas/Houston Health Science Center. CPT code 76360 indicates guidance for biopsies, but it doesnt specify aspirations.

With that in mind, many coders have turned to 76365 (computerized tomography guidance for cyst aspiration, radiological supervision and interpretation), which more accurately describes the guidance procedure. Like 76360, code 76365 carries 1.16 relative value units (RVUs).

The aspiration code certainly does a better job of describing the guidance, Grimes says. And coders have always been told to use the code that is the closest possible to the work being done. However, it wouldnt be wise to make a blanket recommendation that 76365 be used instead since it specifically mentions cyst aspiration. In addition, there is a clear cross-reference to 76360 in the CPT manual, and some carrier software programs may automatically reject the 76365 even though it may be a better code. Its best to check with your local carriers and third-party payers.

As frustrating as this issue has been, coders will be relieved to learn that this conundrum will be solved when CPT 2001 takes effect Jan. 1. At that time, the description of 76360 will change. The new wording is: computerized tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation. This modification brings the definition in line with the fluoroscopy and ultrasound codes, and leaves no doubt that 76360 is the appropriate code to assign for CT guidance during thoracentesis and paracentesis.

Coders should note, however, that while Medicare will begin using the new definition as of Jan. 1, other insurers might not adopt the change as quickly. In the interim, radiology coders should continue to work closely with all carriers to determine which code is preferred.

Note: See cover story for additional radiology coding changes made in CPT 2001.

Subsequent Refers to Same Date of Service

A second issue confronting radiology coders is the definition of subsequent as it appears in code 49081. I often hear coders asking if this means aspirations done in the same session, or later in the day, or the next day, Grimes says. Repeated procedures may be indicated for patients with cancer, for instance, who often experience fluid build-up in the abdomen and require frequent therapeutic aspiration.

Although she again notes that coders should check with the payers in question, the American Medical Association has indicated that subsequent refers to procedures done the same date of service in this instance. This definition is also consistent with other non-radiology codes that use the term subsequent as opposed to the terms repeat or follow up. These latter terms indicate services provided on the same or different date of service for the same or similar clinical reasons as the initial service. However, subsequent refers to additional similar services provided during the same setting."