Therapeutic vs diagnostic para/ thoracentesis
I would like an opinion regarding the coding of diagnostic vs therapeutic taps. Some of these now swing the DRG to the surgical side, so getting them right is paramount. We usually code it based on the physicians intent; was it therapeutic or truly diagnostic. I now have a scenario where the documentation shows a pleural effusion was tapped for both therapeutic and diagnostic reasons. The documentation shows "acute respiratory failure 2/2 pleural effusion" and " concerned about an intra-abdominal malignancy with a malignant effusion - need cytology and additional serologies"
If a procedure is documented as being both therapeutic and diagnostic, how should it be coded?
Angelique Daigle RN BSN CCDS
Comments
Our coders feel that so many specimens go to the lab, that the underlying intent has to be reviewed. In your case, it sounds as if the MD's are needing the cytology and serologies to come to a diagnosis. Because the doctors need these test results, I would argue for diagnostic.
Hope this helps,
Laura