© Copyright 2025 American Medical Association. All rights reserved.
Thoracentesis is a medical procedure aimed at removing excess fluid from the pleural space, which is the area between the parietal and visceral pleura that encases the lungs. This procedure is particularly important in cases where fluid accumulation, known as pleural effusion, can lead to respiratory difficulties and other complications. During thoracentesis, the patient is typically positioned seated, with their head and arms resting on a table to facilitate access to the pleural cavity. The skin surrounding the intended site of the procedure is thoroughly cleansed and draped to maintain a sterile environment. A local anesthetic is then administered to minimize discomfort during the procedure. The physician carefully inserts a needle between the ribs, targeting the pleural cavity to aspirate the fluid. The use of imaging guidance, such as ultrasound, fluoroscopy, or CT, enhances the accuracy of needle placement, ensuring that the procedure is performed safely and effectively. It is important to note that when imaging guidance is utilized, the appropriate CPT® code to report this procedure is 32555, whereas code 32554 is designated for thoracentesis performed without imaging assistance.
© Copyright 2025 Coding Ahead. All rights reserved.
Thoracentesis is indicated for the following conditions:
The thoracentesis procedure involves several critical steps to ensure safety and effectiveness:
After the thoracentesis procedure, the patient is typically monitored for any immediate complications, such as bleeding or pneumothorax. The site of needle insertion may be bandaged, and the patient may be advised to rest for a short period. Follow-up care may include imaging studies to assess the pleural space and ensure that the procedure was successful in relieving symptoms. Additionally, laboratory analysis of the aspirated fluid may be conducted to determine the underlying cause of the pleural effusion, guiding further management and treatment options.
| Short Descr | ASPIRATE PLEURA W/ IMAGING | Medium Descr | THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING | Long Descr | Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 2 | CCS Clinical Classification | 39 - Incision of pleura, thoracentesis, chest drainage |
| RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | GC | This service has been performed in part by a resident under the direction of a teaching physician | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | CR | Catastrophe/disaster related | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | GW | Service not related to the hospice patient's terminal condition | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | GA | Waiver of liability statement issued as required by payer policy, individual case | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 93 | Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. | AF | Specialty physician | AG | Primary physician | AI | Principal physician of record | AM | Physician, team member service | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CG | Policy criteria applied | ER | Items and services furnished by a provider-based, off-campus emergency department | ET | Emergency services | FR | The supervising practitioner was present through two-way, audio/video communication technology | FS | Split (or shared) evaluation and management visit | KT | Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item | KX | Requirements specified in the medical policy have been met | MG | The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional | MH | Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | PL | Progressive addition lenses | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | Q3 | Live kidney donor surgery and related services | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | QL | Patient pronounced dead after ambulance called | RC | Right coronary artery | SA | Nurse practitioner rendering service in collaboration with a physician | SG | Ambulatory surgical center (asc) facility service | TG | Complex/high tech level of care | UA | Medicaid level of care 10, as defined by each state | X3 | Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization; reporting clinician service examples include but are not limited to the hospitalist's services rendered providing comprehensive and general care to a patient while admitted to the hospital |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2013-01-01 | Added | Added |
Get instant expert-level medical coding assistance.