Chest Tube Placement (Tube Thoracostomy)
32551
[Pneumothorax / hemothorax / hemopneumothorax / pleural effusion / empyema], [right / left]
Same
Right [left] chest tube placement (tube thoracostomy)
[Attending name], MD/DO
[Nurse/tech name]
Local: [X] mL 1% lidocaine without epinephrine, [IV analgesia / anxiolysis as needed]
The patient is a [age]-year-old [male/female] with [pneumothorax / hemothorax / pleural effusion / empyema] on the [right / left] requiring tube thoracostomy for [lung re-expansion / drainage / hemostasis]. The risks, benefits, and alternatives of the procedure were discussed with the patient [or patient's surrogate], and informed consent was obtained.
The [right / left] pleural space was entered in the [4th / 5th] intercostal space at the mid-axillary line. [Air rushed out on finger sweep / frank blood / turbid fluid / purulent material] was encountered. The lung was palpable [or not palpable] through the tract. A [28 Fr / 32 Fr / 36 Fr] chest tube was placed [anterosuperiorly / posteroinferiorly] and [X] mL of [sanguineous / serosanguineous / turbid] fluid drained immediately. The tube was connected to water-seal and post-procedure chest radiograph confirmed [lung re-expansion / tube position in the apex / no residual pneumothorax].
The patient was positioned supine with the ipsilateral arm raised and abducted, with the hand behind the head to open the axillary space. The [right / left] lateral chest wall was prepped and draped in sterile fashion using ChloraPrep. Sterile gown and gloves were worn.
The [4th / 5th] intercostal space at the mid-axillary line was identified by palpation of the rib margins. The skin, subcutaneous tissue, intercostal muscles, and parietal pleura were infiltrated with [X] mL of 1% lidocaine, anesthetizing the superior surface of the lower rib to avoid the intercostal neurovascular bundle.
A [2–3 cm] transverse skin incision was made over the [5th / 6th] rib. Blunt dissection with a curved Kelly clamp was carried through the subcutaneous tissue and intercostal muscle along the superior surface of the rib, entering the pleural space with a controlled pop. The tract was widened with the clamp and a gloved finger was inserted to confirm pleural entry, sweep for adhesions, and palpate the lung.
A [28 Fr / 32 Fr / 36 Fr] chest tube was grasped with the clamp and directed [anterosuperiorly for pneumothorax / posteroinferiorly for effusion or hemothorax]. The tube was advanced to the [3rd / 4th] mark at the skin. All side holes were confirmed within the pleural space. Immediate drainage of [air / blood / fluid] was noted. The tube was connected to a water-seal drainage system [with -20 cmH2O suction].
The tube was secured to the skin with a [0-silk] suture and an occlusive petroleum gauze dressing was applied. Post-procedure chest radiograph confirmed [appropriate tube position / lung re-expansion / no residual pneumothorax / reduction in hemothorax].
None
[Pleural fluid sent for cell count, LDH, protein, culture, and cytology as indicated / None]
Minimal
[28 Fr / 32 Fr / 36 Fr] chest tube, right [left] pleural space, [X] mL output, connected to water-seal with [suction / gravity drainage]
The patient tolerated the procedure well and was monitored in [ICU / step-down / floor] in stable condition. The chest tube was functioning with appropriate [air leak / drainage].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** [pneumothorax/hemothorax/effusion/empyema], right/left
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** chest tube placement (tube thoracostomy)
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** pleural pathology requiring tube thoracostomy. Risks, benefits, and alternatives discussed, consent obtained.
FINDINGS: *** intercostal space entered at mid-axillary line. *** encountered on finger sweep. *** mL *** fluid drained immediately. Post-procedure CXR: ***.
PROCEDURE:
Patient positioned supine with ipsilateral arm raised. *** chest wall prepped and draped in sterile fashion.
*** ICS at mid-axillary line identified. Skin, subcutaneous tissue, and pleura infiltrated with *** mL 1% lidocaine along superior rib margin. *** cm incision made over lower rib. Blunt Kelly dissection through intercostal muscle into pleural space. Finger sweep performed. Pleural entry confirmed, no adhesions in tract. *** Fr chest tube directed *** to *** mark at skin, all side holes within pleural cavity. Connected to water-seal with *** suction. Secured with *** suture, petroleum gauze dressing applied.
Post-procedure CXR: ***.
COMPLICATIONS: None
DRAINS: *** Fr chest tube, *** mL output
DISPOSITION: Procedure tolerated well, monitored in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Tension Pneumothorax: Needle Decompression First
Given hemodynamic instability and clinical signs of tension pneumothorax (tracheal deviation, absent breath sounds, hypotension, distended neck veins), immediate needle decompression was performed prior to formal tube thoracostomy. A 14-gauge angiocatheter was inserted into the 2nd intercostal space at the mid-clavicular line. A rush of air was confirmed. The patient's hemodynamics improved immediately. Formal tube thoracostomy was subsequently performed as described above.
Hemothorax
A large-bore [32 Fr / 36 Fr] chest tube was placed posteroinferiorly for drainage of hemothorax. [X] mL of frank blood drained immediately. The tube was connected to an autotransfusion system [or standard water-seal]. If >1500 mL drained immediately or >200 mL/hr for 4 hours, operative intervention should be considered.
Empyema / Complicated Parapneumonic Effusion
Thick, turbid, [foul-smelling] fluid consistent with empyema was encountered on pleural entry. A [28 Fr / 32 Fr] tube was directed posteroinferiorly. The fluid was sent for Gram stain, culture, cell count, pH, LDH, protein, and glucose. Fibrinolytic therapy (tPA/DNase) was discussed with the primary team for loculated empyema. [Thoracic surgery was consulted for consideration of VATS decortication if tube drainage fails.]
Charting Tips
- Document finger sweep explicitly — confirm pleural entry, absence of adhesions, and that all tube side holes are within the pleural cavity. This is the key step that distinguishes a properly placed tube from a malpositioned one.
- Always document immediate output (volume and character) and post-procedure CXR findings specifically. For hemothorax, record initial output — this drives the surgical decision threshold (>1500 mL = operative).
- Document neurovascular bundle avoidance by noting 'dissection along the superior border of the lower rib.' This establishes that proper technique was used if intercostal vessel injury is later alleged.
Billing Tips
- Bill 32551 for tube thoracostomy (2.96 wRVU, 0-day global). Use for standard chest tube placement for pneumothorax, hemothorax, pleural effusion, or empyema.
- Bill 32557 for image-guided pleural catheter placement (3.04 wRVU, 0-day global). Use when ultrasound or CT guidance is used to place a pigtail or small-bore catheter — this replaces 32551, do not bill both.
- 0-day global: no bundled postoperative period. Daily chest tube management (flushes, repositioning checks) does not generate separate CPT charges.
- If a thoracentesis is performed first and then a chest tube is placed in the same session, only the chest tube code is billed — the diagnostic aspiration is bundled.
- Imaging guidance for 32557 requires documentation of real-time imaging, a permanent record, and a separately dictated imaging report or integrated procedure note confirming guidance. Without this documentation, 32551 is the appropriate code.