Gastroenterology Coding Alert

Question: A 52-year-old female presented with worsening abdominal distension and a 15-pound weight gain during the past month. She has a known history of ovarian cancer that was unsuccessfully resected a few months earlier. The increasing distension has made breathing difficult. The gastroenterologist reviewed the prior records and performed an abdominal sonogram, confirming the presence of ascites. He also decided to perform a large volume paracentesis (removal of abdominal fluid, 49080) to provide the patient some relief from her discomfort. How should I report this encounter?New Mexico SubscriberAnswer: In this case, you can report three CPT codes.First, you should use the appropriate E/M code -- such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) -- to report the evaluation and decisions to perform the sonogram and then the paracentesis.Next, report the limited abdominal sonogram with 76705 (Ultrasound, abdominal; real time with image documentation; [...]