ED Coding and Reimbursement Alert

Question: A patient with shortness of breath reports to the ED. The physician obtains pertinent historical information and performs an exam, including auscultation of the lungs, which sound muffled. He then taps on the patient's chest and notes a dull "thud." A chest X-ray confirms the presence of a large pleural effusion. Notes substantiate a level-four E/M.

Based on the evaluation, the physician decides to perform thoracentesis. After the patient is prepped, pleural fluid is withdrawn through a needle into a syringe and sent to the laboratory for analysis. The results indicate the presence of an exudative pleural effusion. How would you code for this encounter?

Answer: This is an example of thoracentesis. For some pleural effusion patients, the ED physician needs to sample the pleural fluid for analysis. When the physician performs thoracentesis removing accumulated fluid from the pleural space but not leaving in a catheter or tube, you'll report the service with 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent).

But during other thoracentesis procedures, the physician inserts a needle into the pleural cavity, inserts a catheter to drain pleural fluid, and then removes the needle. (The catheter remains in place for the entire procedure).

When the physician performs thoracentesis with catheter insertion, code the service with 32422 (Thoracentesis with insertion of tube, includes water seal [e.g. for pneumothorax], when performed [separate procedure]).

On the claim, report the following CPT® codes:

• 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for the thoracentesis
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity...) for the E/M
• Modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99284 to show that the E/M and thoracentesis were separate services
• 71020 (Radiologic examination, chest, two views, frontal and lateral) for the X-ray
• Modifier 26 (Profession al component) linked to 71020 to show you are only coding for the professional portion of the code

Don't forget to demonstrate medical necessity by appending these ICD-9 codes:

• 511.9 (Unspecified pleural effusion) linked to 32421 to represent the pleural effusion and
• 786.05 (Shortness of breath) linked to 99284 and 71020 to represent the patient's breathing difficulty.