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2025 CPT code 32555

Thoracentesis with imaging guidance; aspiration of fluid from the pleural space.

Follow current CPT coding guidelines for thoracic procedures.Proper documentation is crucial for accurate coding and reimbursement.

Modifiers may be applicable depending on the circumstances of the procedure. For example, modifier 59 (Distinct procedural service) might be used if the thoracentesis is performed in conjunction with another distinct procedure.

Medical necessity for thoracentesis is established when a patient presents with a symptomatic pleural effusion causing respiratory compromise or significant discomfort. The procedure is indicated for both diagnostic purposes (fluid analysis) and therapeutic purposes (fluid removal).The need for imaging guidance is dependent on the clinical scenario, the experience of the physician, and the accessibility of imaging technology.

The physician or qualified healthcare professional is responsible for performing the procedure, including patient assessment, imaging guidance, needle insertion, fluid aspiration, and post-procedure monitoring.

IMPORTANT:32554 (Thoracentesis without imaging guidance)

In simple words: This procedure removes excess fluid from around the lungs using a needle guided by imaging (like ultrasound). It helps diagnose lung problems and ease breathing difficulties.

Thoracentesis, using imaging guidance (ultrasound, CT, or X-ray), involves the aspiration of fluid from the pleural space using a needle or catheter.The procedure is performed to diagnose and/or treat pleural effusions, relieving pressure and improving respiratory function. Imaging guidance ensures accurate needle placement, minimizing the risk of complications.

Example 1: A patient presents with shortness of breath and chest pain.A chest X-ray reveals a large pleural effusion.An ultrasound-guided thoracentesis is performed to remove the fluid for diagnostic analysis and symptom relief., A patient with known lung cancer experiences increasing dyspnea.A CT-guided thoracentesis is performed to remove malignant pleural fluid, improving respiratory function and alleviating discomfort., A patient with suspected pneumonia develops a pleural effusion.An ultrasound-guided thoracentesis is performed to obtain a sample of pleural fluid for microbiological analysis, guiding antibiotic therapy.

* Detailed patient history including symptoms, relevant medical history, and allergies.* Pre-procedure imaging (chest X-ray, ultrasound, or CT scan) to confirm the presence and location of the pleural effusion.* Documentation of the procedure itself, including needle placement, volume of fluid removed, and any complications.* Post-procedure imaging (optional, depending on clinical circumstances) to assess for pneumothorax or other complications.* Pathology report of the aspirated fluid.

** Imaging guidance (ultrasound is most common, but CT or X-ray may be used) is an integral part of the procedure and is included in code 32555. Code 32554 is used when imaging guidance is not used.Always ensure proper documentation to support medical necessity and procedural details.

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