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Modifier Coding Alert

Reader Question:

Remember Modifier Pair for ED E/M, Thoracentesis

Question: A patient with shortness of breath reports to the emergency department (ED). The physician obtains pertinent historical information and performs an exam, including auscultation of the lungs, which sound muffled.  He then taps on the patient’s chest and notes a dull “thud.” A chest X-ray confirms the presence of a large pleural effusion. Notes substantiate a level-four E/M.

Based on the evaluation, the physician decides to perform thoracentesis without imaging guidance. A nurse practitioner (NP) preps the patient, and the provider withdraws pleural fluid through a needle into a syringe and sends it to the laboratory for analysis. In order to facilitate continued drainage, the provider leaves the catheter in place. (The ED facility owns the x-ray equipment we used.) The results indicate the presence of an exudative pleural effusion. How would you code for this encounter?

Kentucky Subscriber

Answer: Since you’re coding for services the provider performed with facility-owned equipment, and there is evidence of a separate E/M service, you’ll need to include a pair of modifiers to make this claim fly.

First, report 32556 (Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance) for the pleural effusion. Then, report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity…) for the E/M visit with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to show that the E/M and thoracentesis were separate services.

Lastly, report 71020 (Radiologic examination, chest, two views, frontal and lateral) for the X-ray with modifier 26 (Professional component) appended to show you are only coding for the professional portion of the code.

Don’t forget to demonstrate medical necessity by including these ICD-10 codes:

  • Append J91.8 (Pleural effusion in other conditions classified elsewhere) to 32556 to represent the pleural effusion.
  • Append R06.02 (Shortness of breath) to 99284 and 71020 to represent the patient’s breathing difficulty.

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