Pulmonology Coding Alert

When coding thoracentesis, you should understand the reason for the procedures first, then assign the various diagnoses carefully to reduce the chance of denial.

Pulmonologists perform thoracentesis to remove fluid from the pleural space for both diagnostic and therapeutic reasons (see box on page 85). The physician's notes should indicate his or her reasoning for the thoracentesis.

"The coder should use the physician's procedure notes when coding to ensure reporting of the correct diagnosis(s)," says Mary Mulholland, RN, BSN, CPC, a senior coding and education specialist for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "Inappropriate reporting of services may be misconstrued as intentional if the incorrectly reported procedure is reimbursed at a higher rate than the other procedure."

During a diagnostic thoracentesis (32000*, Thora-centesis, puncture of pleural cavity for aspiration, initial or subsequent), the physician removes the pleural fluid and sends it for testing. Therapeutic thoracentesis (32002, Thoracentesis with insertion of tube with or without water seal [e.g., for pneumothorax] [separate procedure]) occurs when the doctor removes the fluid to allow the patient to breathe more easily.

Usually, the initial patient visit will focus on obtaining accurate medical information to help the pulmonologist decide if a thoracentesis is the most appropriate procedure. In this case, you should report the appropriate E/M code (99201-99233). The proper code depends on the location of the service, nature of the service performed and intent of the requesting physician (in transferring care of the pulmonary problem to the pulmonologist).

If the pulmonary physician performs the thoracentesis on the same day as the E/M service, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. The physician may also use chest x-rays or ultrasound to visualize the pleurae, says Charlie Strange, MD, FCCP, director of the medical intensive care unit at the Medical University of South Carolina in Charleston

Frequently, the pulmonologist evaluates the patient and then performs the thoracentesis procedure at a later date. When reporting the thoracentesis in this instance, you should bill 32000 along with the appropriate E/M code because 32000 is a "starred" procedure, meaning the code only includes the procedure and not any pre- or postoperative services. Also, you should append modifier -25 to the E/M code to show that it is separate from the thoracentesis.

The diagnosis should clearly reflect the medical necessity for the care given the patient. CPT does not require different diagnoses for the E/M service and the procedure. When it's appropriate, use the same diagnosis for both. But if the diagnosis is different for the E/M and the procedure, make sure to properly link the diagnoses to the specific service codes.

The ICD-9 codes paint a clear picture of the patient's symptoms, provide the medical necessity for the procedure(s) and explain why the physician was medically justified in initiating his or her plan of care, Mulholland says. A symptom such as painful respiration (786.52) may be the only diagnosis available during the initial visit. After a thoracentesis, however, the physician determines that the patient has a pleural effusion (511.9). You should use the effusion as the diagnosis for that day's service.

For example, a patient in the hospital complains of painful respiration. The pulmonologist performs an examination and orders a chest x-ray. The x-ray reveals pleural effusion. The pulmonary physician then performs a thoracentesis to establish a specific diagnosis.

To code this scenario, you should report a subsequent hospital care code (e.g., 99233, Subsequent hospital care, per day, for the evaluation and management of a patient ) and 32000 for the thoracentesis. "The visit diagnosis should be coded as 511.9 because the specific diagnosis that caused the effusion is yet to be determined pending laboratory testing of the fluid," Strange says. "You should use the effusion as the diagnosis for that day's service." In addition, you should append the E/M code with modifier -25.

After completing a thoracentesis, the pulmonologist often sees the patient to discuss the findings and further treatment plans. You should report this encounter as an established patient visit (99211-99215) or subsequent inpatient care (99231-99233). You should consider basing the level of service on the amount of face-to-face time the pulmonary physician spends with the patient in an outpatient setting or the floor/unit time for an inpatient. The rule is that if the pulmonologist spends more than 50 percent of the visit counseling and coordinating care, you can code the service based on time.

The physician's documentation must specify the total duration of the visit and the amount of time spent in counseling the patient. It should also describe the encounter. The pulmonologist should include what was discussed, the results of the various tests, an explanation of the current situation and an outline of the treatment recommendations.

You can report only the time spent in direct contact with the outpatient or on the same floor or unit when providing care for the inpatient. The effort the physician spends evaluating the results of the test and preparing for the follow-up visit may not be billed separately. These components are included in the decision-making portion of the E/M code. In addition, you should not append modifier -51 (Multiple procedures) to 32000 and 32002. If you add -51, you will incur unnecessary payment reduction.

Inserting the needle during the thoracentesis may introduce air into the pleural space. Consequently, the pulmonologist frequently orders chest x-rays (71020, Radiologic examination, chest, two views, frontal and lateral) after the procedure to check for pneumothorax and to look for any other abnormalities the fluid may have obscured. If the pulmonologist owns the x-ray equipment, he or she can bill 71020. On the other hand, if the physician sends the patient to an outside facility for x-rays, radiologists at the facility will likely review the films and issue a report back to the pulmonologist. You should factor any time the pulmonary physician spends reviewing the x-rays and the radiologist's report into the medical decision-making portion of the E/M service.

When the physician uses ultrasonic guidance, however, he or she may bill 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) with modifier -26 (Professional component) if the procedure is performed in a facility setting.

The Medicare Fee Schedule for 2002 revised the status of A4550 (Surgical trays), Mulholland points out. "The surgical tray is now bundled into the procedure, and therefore it is not separately billable."