Radiology Coding Alert

Question: If we precertify a specific interventional procedure based on one diagnosis, but the radiologist determines the patient requires an additional procedure once he's working on the patient, may we report the second procedure, too?

Tennessee Subscriber

Answer: You should report the additional procedure and diagnosis, assuming your documentation describes the medical necessity for them. Tip: Your practice may be able to prevent dealing with this problem by precertifying a code range.

Example: Your practice precertifies thoracentesis (32421, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for a patient with pleural effusion (511.9, Unspecified pleural effusion). After the radiologist begins the procedure, he aspirates a small amount of blood and pus from the patient's lung. He determines the patient actually has a hemothorax (511.89, Other specified forms of effusion, except tuberculous). The radiologist inserts a chest tube and performs thoracostomy to remove the fluid (32551, Tube thoracostomy, includes water seal [e.g., for abscess, hemothorax, empyema], when performed [separate procedure]).

Before the procedure, let the insurer's precertification department know that the physician may perform other procedures if he discovers additional diagnoses requiring treatment. For insurers who want you to precertify only the intended procedure (in this case, 32421) based on the confirmed diagnosis, you can precertify the expected service but repeat that the radiologist may perform and report more procedures if medically necessary.

If, after the surgery, the insurance company denies the additional procedure (in this case, 32551), appeal by citing the date your practice requested precertification, your attempt to precertify a code range, and the fact that the radiologist diagnosed hemothorax during the thoracentesis.