Radiology Coding Alert

Question: If we precertify a specific interventional procedure based on one diagnosis, but the radiologist determines the patient requires an additional procedure once he's working on the patient, may we report the second procedure, too? Tennessee Subscriber Answer: You should report the additional procedure and diagnosis, assuming your documentation describes the medical necessity for them. Tip: Your practice may be able to prevent dealing with this problem by precertifying a code range. Example: Your practice precertifies thoracentesis (32421, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for a patient with pleural effusion (511.9, Unspecified pleural effusion). After the radiologist begins the procedure, he aspirates a small amount of blood and pus from the patient's lung. He determines the patient actually has a hemothorax (511.89, Other specified forms of effusion, except tuberculous). The radiologist inserts a chest tube and performs thoracostomy to remove the fluid (32551, Tube thoracostomy, includes [...]