Physician performed an aspiration thoracentesis on a patient in observation status in the hospital. The patient has advanced lung cancer with malignant pleural effusion. Later the same day, due to continued accumulation of fluid. the patient was returned to the procedure room and the same physician performed a repeat thoracentesis, Report diagnosis and procedure codes, do not report observation codes....
What are the ICD-9CM and CPT codes, and assign the correct codes and modifier for this encounter???? anyone please help.
The ICD-9-CM codes would be 162.9 and 511.81. According to ICD-9 codes you would code the neoplasm first. You will find 162.9 under neoplasm of bronchus and lung.
The first CPT code would be 32421, thoracentisis , puncture of pleural cavity. I am still trying to find the CPT code for the second procedure. I hi\ope this helps you
To determine the correct ICD-9-CM and CPT codes for this encounter, we need to understand the specific diagnosis and procedure performed.
Based on the information provided, the diagnosis is advanced lung cancer with malignant pleural effusion, and the procedure performed is an aspiration thoracentesis.
1. ICD-9-CM Diagnosis Code:
For the diagnosis of advanced lung cancer with malignant pleural effusion, you would use the appropriate code from the Neoplasm section in the ICD-9-CM coding manual. Without specific details about the type or stage of lung cancer, it is difficult to provide an accurate code. As an AI bot, I don't have access to the latest ICD-9-CM codes. However, you can refer to the ICD-9-CM coding manual or consult a healthcare professional for the specific diagnosis code.
2. CPT Code for the Procedure:
The CPT code for the aspiration thoracentesis in this case would be 32554. This code represents the procedure of aspiration or drainage of the pleural cavity using needle or catheter, including imaging guidance, when performed. This code covers both the initial and repeat thoracentesis procedures.
3. Modifier:
You mentioned that the patient underwent a repeat thoracentesis on the same day due to continued accumulation of fluid. In this case, you would append modifier 76 (Repeat procedure by the same physician) to the CPT code 32554 to indicate that the procedure was a repeat one performed by the same physician.
Please note that coding guidelines and requirements may vary, and it is always recommended to consult the latest coding manuals or seek assistance from a certified medical coder or healthcare professional for accurate coding and documentation.