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Modifier Coding Alert

Reader Question:

Know CPT® Rules to Nail Bilateral Claims

Question: Our physician recently performed a diagnostic thoracentesis for a patient with a pleural effusion at a local hospital. Notes indicate that the patient was only scheduled for treatment on a right-sided pleural effusion, but the physician discovered fluid on the left side of the pleural cavity as well. Notes indicate that the physician used fluoroscopic guidance for both procedures. Can I report this as a bilateral procedure?

Nebraska Subscriber

Answer: Yes, you can. On the claim, report 32555 (Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) with modifier 50 (Bilateral procedure) appended to show that the physician had to perform thoracentesis on both sides of the patient’s pleural cavity. 

Good idea: Check your payer’s status on the use of modifiers LT (Left side) and RT (Right side). Some of them might want you to report 32555-RT and 32555-LT-50 to prove the bilaterality of the procedure.