Gastroenterology Coding Alert

Question: Our gastroenterologist performed a paracentesis (49080) but didnt get any fluid even though he went to three different sites. Should I bill this as a paracentesis or an attempted paracentesis?

Minnesota Subscriber

 
Answer: You should report this as a reduced service by attaching modifier -52 to the procedure code because no fluids were drawn. Its not uncommon for a paracentesis procedure to come up dry, and many insurers will pay the full fee in this situation, even though youre reporting a reduced service.
 
If the paracentesis is repeated on the patient the next day, the reduced services modifier also helps explain to the payer the need to repeat the procedure so quickly. Without the modifier, it will look as if your gastroenterologist did the same procedure on the same patient two days in a row.
 
You should also note that there are two codes for paracentesis. The initial session is reported with 49080 (peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; initial). Report all subsequent sessions with 49081 (... subsequent).