Remember That Imaging Guidance Is Included in 32555
Question: A patient presents with recurrent unilateral pleural effusion, worsening dyspnea, and unexplained weight loss. Chest X-rays confirmed moderate left pleural effusion. The pulmonologist performed diagnostic thoracentesis with ultrasound guidance and removed 800 mL of fluid for cytology and laboratory analysis. How should we report the encounter? Connecticut Subscriber Answer: Use 32555 (Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) to report the diagnostic thoracentesis with ultrasound guidance. A common coding error is reporting the ultrasound guidance separately with 32555, but that is incorrect because the imaging guidance is inherently included in the procedure. Assign J90 (Pleural effusion, not elsewhere classified) to report the patient’s moderate left pleural effusion. The term “not elsewhere classified” indicates that the code is appropriate for the case because there is not a more specific code in the ICD-10-CM code set for the condition. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
