Radiology Coding Alert

Question: Which code is appropriate for an ultrasound guided thoracentesis? South Carolina Subscriber Answer: If the radiologist performed both the thoracentesis and the guidance, you may report both separately. Guidance: For the ultrasound guidance, report 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). Remember that ultrasound guidance procedures "require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized," according to CPT's "Diagnostic Ultrasound" guidelines. Procedure: For patients who undergo thoracentesis, removal of excess fluid or air in the space between the lungs and chest wall, the medical record should describe clearly how the physician removed the fluid and which equipment he used. This information will help you choose the correct code. If the radiologist uses a syringe and [...]