tci ED Coding & Reimbursement Alert - 2011 Issue 3

You Be the Coder: Coding 'Needle to Chest' Procedures

Question: A patient reports to the ED via ambulance. The emergency medical technician (EMT) says the patient had sudden chest pain, rapid heart rate and rapid breathing. The physician orders a two-view chest x-ray, and diagnoses a spontaneous pneumothorax. Encounter notes indicate that the physician used "needle to chest for spontaneous pneumothorax." Notes indicate the encounter included a level-five E/M service. How should I code this encounter?Montana SubscriberAnswer: You physician performed a needle thoracentesis for this patient's collapsed lung. On the claim, report the following:32421 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for the...

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