Gastroenterology Coding Alert

Question: The gastroenterologist performed peritoneocentesis on a patient to drain fluid from his abdominal cavity. The sessions were two days apart, but we're curious about how to report the encounters. Can we code for both the initial and subsequent peritoneocentesis on the claim?

Missouri Subscriber Answer: Yes, you can. When you file the claim,  you should:

 report 49080 (Peritoneocentesis, abdominal paracentesis, or peritoneal lavage [diagnostic or therapeutic]; initial) for the first session.

 report 49081 (... subsequent) for the second session. Heads-up: Peritoneocentesis (a.k.a. abdominal paracentesis or peritoneal lavage) is often done over several sessions. CMS prohibits reporting both codes on the same date, but if you report 49080 and 49081 on different dates of service, the insurer should not bundle the codes.

Also, when your gastro performs peritoneocentesis with imaging guidance, you may be able to report  these codes:

 76360 - Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation

 76942 - Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) image supervision and interpretation. Check with the individual payer for its policies on imaging guidance before filing a peritoneocentesis claim with 76360 and/or 76942 included.