Pulmonology Coding Alert

Clue: A catheter tells you therapeutic instead of diagnosticPatients who develop pleural effusions often require a thoracentesis to diagnose or treat the condition. If you fail to identify the procedure and equipment, you could end up selecting 32421, rather than 32422 -- a difference of about $38 per procedure.Look for these clues to submit your thoracentesis claims correctly.Syringe Use Is a Factor in 32421 ClaimsFor some patients with a pleural effusion, the pulmonologist will need to obtain a small sample of pleural fluid for analysis. "The physician may be able to determine the cause of the pleural effusion after lab analysis of the fluid," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.When the pulmonologist performs a thoracentesis by withdrawing fluid through a needle connected to a syringe to diagnose the patient's condition, you'll report the service with 32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent), says Pierre Edde, MD, head of the pulmonology/critical care/sleep division at Pennsylvania's Uniontown Hospital."The physician performs the procedure to obtain a sample of fluid to make the diagnosis," Edde says. The physician will send the patient's sample to the laboratory, which will determine whether the fluid is transudative (usually due to increased hydrostatic pressure from cardiac, liver or renal failure) or exudative (usually from pleural involvement from pneumonia, malignancy, connective tissue diseases, etc.).Example: An established patient with shortness of breath reports to the office. The pulmonologist 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 pleural effusion.Office notes substantiate a level-four E/M. Based on the evaluation, the pulmonologist decides to perform a diagnostic 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 After the patient is prepped, pleural fluid is withdrawn through a needle into a syringe and sent to the laboratory for analysis.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.This is an example of diagnostic thoracentesis. On the claim, you should report the following:• 32421 for the thoracentesis• 511.9 (Unspecified pleural effusion) linked to 32421 to represent the pleural effusion• 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; 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 99214 to show that the E/M and thoracentesis are separate services• 786.05 (Shortness of breath) linked to 99214 to represent the patient's breathing difficulty.• 71020 [...]