Know When to Report Thoracostomy vs. Thoracentesis Procedures
Explore the procedure differences and how to get the correct code every time. A patient presents to the emergency department (ED) with trouble breathing and chest pain. A chest X-ray reveals fluid buildup in the pleural cavity, the space between the inner chest wall and the lungs. The surgeon successfully drains the fluid using a catheter. Without seeing the documentation, is this procedure a thoracostomy or thoracentesis? Both involve removing air, blood, or fluid from the pleural cavity. The difference lies in procedural technique. Miscoding these procedures and using incorrect modifiers may lead to denials. Read on to discover how to distinguish between an open thoracostomy and thoracentesis based on documentation, apply modifiers correctly, and identify when imaging is separately reportable. Understand the Clinical Indications Tube thoracostomy is performed to place an indwelling catheter to drain air (pneumothorax), blood (hemothorax), pus (empyema), or fluid from the pleural cavity. Injuries, cancer, inflammation, and infections are some reasons why air or fluid may gather in the pleural space. Fluid collection in the pleural cavity (pleural effusion) may be caused by many conditions from heart failure to cancer, resulting in chest pain and difficulty breathing. Examples of ICD-10-CM codes supporting thoracostomy include: Coding tip: Medical necessity criteria varies by payer. Verify payer-specific requirements before claim submission. Learn How to Code an Open Thoracostomy Procedure Report an open tube thoracostomy with 32551 (Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure)). While both tube thoracostomy and thoracentesis (32554-32555 [Thoracentesis, needle or catheter, aspiration of the pleural space …]) share many indications, thoracostomy is an open procedure. Open procedures involve cutting down through layers of tissue to reach the surgical site. In a thoracostomy, the surgeon uses a local anesthetic like lidocaine on the area and makes an incision at the fourth or fifth intercostal space (between the ribs), to the side of the pectoralis major muscle. Note that a thoracentesis may start the same way, with local anesthetic and a small incision. However, in a thoracostomy, the surgeon continues to dissect down to the rib using blunt and/or sharp dissection through the chest wall. The documentation may describe using a Kelly clamp to puncture the parietal pleura. This means the pleural cavity has been entered, as the pleural space is bounded by the parietal pleura on the inner chest wall side and the deeper visceral pleura that lines the surface of the lungs. The surgeon then inserts a chest tube into the pleural cavity for drainage. Code 32551 includes connecting the tube to a drainage system like a water seal to both help drainage and prevent air from entering the pleural cavity. The surgeon then sutures the chest tube in place and confirms placement of the tube with a chest X-ray. When the pleural cavity is filled with pus (empyema), the surgeon may perform more invasive open procedures involving rib resection or the creation of an open flap for drainage. In this case, you’ll assign either 32035 (Thoracostomy; with rib resection for empyema) or 32036 (… with open flap drainage for empyema). Identify Removal of a Tube Thoracostomy To report removal of a chest tube placed via 32551, assign the appropriate level-E/M code for the encounter. Do not use 32552 (Removal of indwelling tunneled pleural catheter with cuff), as this is used to report the removal of an indwelling tunneled pleural catheter with cuff that was already placed and coded with 32550 (Insertion of indwelling tunneled pleural catheter with cuff). Know What ‘Separate Procedure’ Means Tube thoracostomy (32551) is a “separate procedure” and is not separately reportable if the surgeon performs it at the same encounter as another open thorax procedure on the ipsilateral (same) side. An exception is if they perform the thoracostomy on the contralateral (opposite) side of the body from the other open procedure of the thorax. For example, if a patient requires major reconstruction of their left chest wall (32820 [Major reconstruction, chest wall (posttraumatic)]) and the surgeon places a chest tube for hemothorax on their right side, you may append modifier 59 (Distinct procedural service) to 32551. The documentation must support that 32551 was both clinically appropriate and distinct to use modifier 59. Coding tip: If a surgical thoracoscopy converts to an open thoracostomy, you’ll only report the open procedure (32551). If the findings from a diagnostic thoracoscopy lead to a decision to perform an open thoracostomy, then you may report both codes with modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) appended to 32551. Report Thoracostomy Performed During Critical Care You may report thoracostomy procedures separately from critical care service codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)). For example, if the provider places a chest tube in a patient during 30 minutes of critical care, you’ll report the tube thoracostomy with 32551 and append modifier 25 to the critical care code (99291-25). Remember to check third-party payer guidelines, as their bundling and modifier guidance may differ from CPT® guidelines and CPT® Assistant guidance. When the surgeon places a chest tube during a critical care encounter, exclude the time spent performing the thoracostomy from the total critical care time reported with 99291 and +99292. According to CPT® guidelines, the time spent performing separately reportable procedures is not included in the total critical care time. Navigate Coding Multiple Thoracostomies If the surgeon performs a tube thoracostomy on both sides of the body, append modifier 50 (Bilateral procedure) to 32551. For example, a patient may have a malignant pleural effusion around both lungs and require tube placement on the left and right sides. For multiple tube thoracostomies required on the same side on the same day, you may append modifier 59. Coding tip: Some payers may prefer laterality modifiers RT (Right side) and LT (Left side) on separate claim lines rather than 32551-50 reported on a single line. For example, they might ask you to report 32551-RT and 32551-LT for bilateral tube thoracostomies. Learn How Thoracostomy Differs From Thoracentesis Coding Unlike thoracostomy, codes for thoracentesis are selected based on if imaging guidance is used; choose from these codes: As described above, thoracostomy procedures 32551, 32035, and 32036 are all open procedures. In comparison, thoracentesis codes 32554 and 32555 use a needle or catheter to enter the pleural cavity, and an attached syringe draws out the air or fluid from the pleural cavity. Think of an amniocentesis procedure, except instead of drawing amniotic fluid from the amniotic sac, the procedure draws fluid or air from the pleural cavity. The terms “aspirate” or “aspiration” may be used in the documentation. The catheter or needle is removed at the end of the session. Thoracentesis may be therapeutic or diagnostic. A diagnostic thoracentesis may involve culturing the fluid withdrawn to identify the bacteria responsible for an infection. Coding tip: For percutaneous pleural drainage, see 32556 (Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance) and 32557 (… with imaging guidance). During these procedures, the physician uses a needle to puncture the pleural cavity like thoracentesis, but then uses a guidewire to place a catheter for drainage that is left in place (indwelling). For a tunneled pleural catheter with cuff that is left in place, see 32550. Learn All About Imaging Physicians will often perform imaging prior to the placement of a chest tube in a thoracostomy to evaluate the contents of the pleural cavity. According to CPT® Assistant, Volume 22, Issue 11, you may report diagnostic ultrasound code 76604 (Ultrasound, chest (includes mediastinum), real time with image documentation) with 32551 if the “entire service is performed and documented.” Per AHA Coding Clinic® for HCPCS, Volume 14, Issue 2, append modifier 59 to a diagnostic imaging procedure when its findings lead to the thoracostomy and a National Correct Coding Initiative (NCCI) edit exists between the two codes. Do not report 75989 (Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation) with 32551 since 75989 describes radiological guidance for percutaneous, not open, drainage. According to AHA Coding Clinic® for HCPCS, Volume 18, Issue 1, separate imaging (for example, 71045 [Radiologic examination, chest; single view]) to confirm chest tube placement or check for complications is not separately reportable with 32551 for the professional component. If the postprocedural imaging is unrelated to the thoracostomy procedure, you may report the imaging separately with modifier 59 appended. For example, a patient may have a thoracostomy and later that day need a chest X-ray to diagnose the source of respiratory distress. Conclusion Choosing the correct thoracostomy or thoracentesis code depends on the procedural technique, not on tube size or the substance drained. For open thoracostomy procedures (32551, 32035, 32036), look for documentation of dissection through the layers of the chest wall. For thoracentesis (32554-32555), documentation involves drainage with a needle or catheter without an open approach. Code 32551 is a “separate procedure” and is bundled into more comprehensive open thorax procedures unless performed on the opposite side and documented as distinct. When in doubt, return to the operative report and read the procedure description thoroughly to determine the approach. Angela Halasey, BS, CPC, CCS, Contributing Writer
Coding tip: Code 32551 is considered a “minor surgical procedure” with a global period of 000 (zero days). If a significant and separately reportable evaluation and management (E/M) service is provided on the same day by the same physician or qualified healthcare professional, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code. The E/M service must not have led to the decision to perform the thoracostomy.
