A physician performed an aspiration via 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.



Assign the correct codes and modifier for this encounter.



ICD-9-CM and CPT Code(s):__________________



ICD-10-CM Code(s):

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To determine the correct diagnosis and procedure codes for this encounter, we will need to gather some information:

1. Diagnosis: The patient has advanced lung cancer with malignant pleural effusion.

2. Procedure: The physician performed an aspiration via thoracentesis on the patient in observation status, and later performed a repeat thoracentesis due to continued accumulation of fluid.

Now, let's find the appropriate codes:

ICD-9-CM and CPT Codes:
1. Diagnosis Code: In ICD-9-CM, the appropriate diagnosis code for advanced lung cancer is 162.9. For malignant pleural effusion, the code is 511.9.

2. Procedure Code: The appropriate CPT code for thoracentesis is 32554.

Modifiers: Modifiers may be required to provide additional information about the procedure. However, based on the information provided, it is not clear if a modifier is necessary. A modifier should be used only if there is specific documentation that indicates a need for one.

Please note that the codes provided are based on the ICD-9-CM and CPT code sets, which have been replaced by ICD-10-CM and CPT code sets. To find the equivalent ICD-10-CM codes, it is recommended to consult the current coding manuals or an appropriate coding resource. The ICD-10-CM codes may vary based on the specificity of the documentation.

It is important to consult the official coding guidelines, the patient's medical record, and any specific guidelines provided by the coding authorities for accurate coding.