Ask Dr. Z

DR. Z, I am a coder having a disagreement with another department on coding a tunneled PleurX catheter for malignant pleural effusion. The doctor writes in the progress notes " 12 pleural cath ..place via ultrasound guidence 1600m of fluid removed. He types up a report that states "ultsonography guided right pleurX catheter placement...Ultrasonography was performed at the bedside and revealed a large right pleural effusion which was echoic in nature, suggesting blood or thick fluid. A mark was placed in the patient's chest for proper needle placement. The patient was then cleaned with ... and a drape was placed. The right pleurX cahterter was placed in the right midaxillary line. It was tunneded under the skin to about 7 mm into the chest. There was good drainage of serosanguineous fluid which was removed without difficulity. I think the codes should be 32250 and 75989 but the department insist that 78989 should not be added because the ultrasound guidence is FOR LOCALIZATION: THis is the response representing the department: I have to ask whether the procedure was actually guidance vs. localization. To report ultrasound guidance I would expect documentation to support continuous ultrasound guidance as the following Thoracic Intervention Seminar demonstrates. This particular patients procedure note only describes using ultrasound to locate a large pleural effusion.The operative report does state Ultrasonography Guided Right PleurX Catheter Placement. It may be poor physician documentation but I would imagine that it was used only to localize. Thoracentesis under ultrasound guidance is usually performed with the patient in a sitting position on the edge of the bed, leaning forward with the patient's arms resting on a bedside table. When the patient is not able to be placed in a sitting position, the lateral decubitus or supine position can be used. Preprocedural ultrasound evaluation can localize the pleural fluid pocket and skin entry site at the posterior intercostal space, which is prepared and draped in a sterile manner. A skin entry site is then anesthetized using 1% lidocaine with epinephrine. The access site should be along the superior margin of the rib to avoid the injury to the intercostal artery, which runs along the inferior border of the rib. After making a small skin incision, an 18-gauge over-the-needle sheath is then advanced into the pleural fluid under continuous ultrasound guidance." What do you think should be coded for this procedure 33251 and 75989 or just 33251? I think they are getting 75989 mixed up with 76937. Thanks so much for your website and books. I could not do my job without them!! Kelly Hill Coder