Thoracentesis
32555
-
76942— Ultrasound guidance with permanent image documentation
[Right / left] pleural effusion, [diagnostic / therapeutic]
Same
Ultrasound-guided [right / left] thoracentesis, [diagnostic / therapeutic]
[Attending name], MD/DO
[Nurse/tech name]
Local: [X] mL 1% lidocaine without epinephrine
The patient is a [age]-year-old [male/female] with a [right / left] pleural effusion presenting for [diagnostic evaluation / symptomatic relief of dyspnea]. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained. Pre-procedure INR was [value]; platelet count was [value].
Ultrasound confirmed a [right / left] pleural effusion measuring [depth] cm at the puncture site. The fluid appeared [anechoic / complex / echogenic]. [X] mL of [straw-colored / serosanguineous / bloody / turbid / milky] fluid was drained without complication. Post-procedure assessment demonstrated no pneumothorax.
The patient was positioned sitting upright leaning forward with arms resting on a padded overbed table. Ultrasound was used to confirm the location and depth of the [right / left] pleural effusion and to identify the diaphragm, lung, and surrounding structures. The optimal puncture site was marked at the [posterior / posterolateral] chest wall in the [___ intercostal space], with a measured fluid depth of [X] cm. An ultrasound image was saved documenting the effusion and the planned puncture site.
The skin was prepped with ChloraPrep and draped in sterile fashion. The skin, subcutaneous tissue, and periosteum of the superior rib margin were infiltrated with [X] mL of 1% lidocaine. A small skin nick was made with an 18-gauge needle to minimize drag.
A thoracentesis needle [or 8.5 Fr pigtail catheter kit] was advanced over the superior margin of the lower rib under ultrasound guidance, with gentle aspiration. Entry into the pleural space was confirmed by free flow of pleural fluid. The needle was advanced [or the catheter was deployed over the wire using Seldinger technique].
For therapeutic thoracentesis: fluid was drained using vacuum bottles. A total of [X] mL of [straw-colored / serosanguineous] fluid was removed. No more than 1500 mL was drained in a single session to reduce the risk of re-expansion pulmonary edema. The needle [catheter] was removed and pressure was applied to the site.
Fluid was sent for [LDH, protein, albumin, pH, cell count with differential, Gram stain and culture, cytology]. A post-procedure ultrasound confirmed no pneumothorax. A post-procedure chest radiograph was [obtained / deferred given clinical stability].
None
Pleural fluid sent for: LDH, protein, albumin, pH, cell count with differential, Gram stain and culture, [cytology]
None
None. Thoracentesis needle removed at end of procedure. [X] mL pleural fluid drained.
The patient tolerated the procedure well. Oxygen saturation remained stable throughout. Post-procedure assessment confirmed no pneumothorax. The patient was monitored for 1 hour post-procedure.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** pleural effusion, diagnostic/therapeutic
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Ultrasound-guided *** thoracentesis
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** pleural effusion presenting for ***. INR ***, platelets ***. Risks and benefits discussed, consent obtained.
FINDINGS: Ultrasound confirmed *** pleural effusion, depth *** cm, appearing ***. *** mL *** fluid drained. No pneumothorax on post-procedure assessment.
PROCEDURE:
Patient seated upright leaning forward. Ultrasound confirmed *** pleural effusion at *** ICS, depth *** cm. Diaphragm and lung margins identified. Image saved. Site marked.
Skin prepped and draped in sterile fashion. *** mL 1% lidocaine infiltrated along superior rib margin. Thoracentesis needle advanced over superior margin of lower rib under ultrasound guidance. Free pleural fluid return confirmed. *** mL *** fluid drained via vacuum bottles. No re-expansion symptoms. Needle removed, pressure held.
Fluid sent for: LDH, protein, albumin, pH, cell count, Gram stain/culture, cytology.
Post-procedure: no pneumothorax.
COMPLICATIONS: None
SPECIMENS: Pleural fluid, per above
DISPOSITION: Patient tolerated procedure, monitored x1 hour in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Diagnostic Thoracentesis (Small Volume)
Only 50–60 mL of pleural fluid was aspirated for diagnostic purposes. Fluid was sent for LDH, protein, albumin, pH, cell count with differential, Gram stain and culture, and cytology. Light's criteria will be applied to differentiate exudate from transudate.
Large Volume — Re-expansion Pulmonary Edema Precautions
Given the large effusion (>1000 mL anticipated), drainage was limited to 1500 mL in a single session. The patient was monitored for chest tightness, cough, or hypoxia during drainage, any of which would prompt immediate cessation and suggest re-expansion pulmonary edema. The patient tolerated drainage of [X] mL without these symptoms.
Post-Procedure Pneumothorax
Post-procedure chest radiograph demonstrated a [small / moderate] pneumothorax. The patient was [asymptomatic / symptomatic]. A [small-bore pigtail catheter / chest tube] was placed in the [right / left] pleural space with resolution of the pneumothorax on repeat imaging.
Charting Tips
- Document ultrasound image confirmation of effusion, depth measurement, and identification of the diaphragm — required for billing CPT 76942 (ultrasound guidance). The image must be permanently saved in the chart.
- Record total volume drained, fluid character, and all labs sent. For Light's criteria to be applied, LDH and protein must be measured in both the fluid and serum simultaneously — note if serum labs were ordered.
- Document pre-procedure coagulation status (INR, platelets) if borderline. Most guidelines accept INR <2.0 and platelets >50,000 without correction for thoracentesis. Documenting these values protects against bleeding complication claims.
Billing Tips
- Bill 32554 for thoracentesis without imaging guidance (1.77 wRVU, 0-day global). Use for landmark-based needle aspiration of pleural fluid.
- Bill 32555 for thoracentesis with imaging guidance (2.21 wRVU, 0-day global). Use when real-time ultrasound is used. Document real-time needle visualization, a permanent image record, and medical necessity for guidance. Ultrasound guidance is now standard of care for thoracentesis, and most institutions use 32555 routinely.
- 32555 includes the imaging guidance. Do not separately bill ultrasound (76942) in addition to 32555. The guidance wRVU is bundled into the procedure.
- 0-day global: thoracentesis can be billed separately from a same-day E/M if a significant, separately identifiable evaluation is documented (modifier -25 on the E/M).
- For recurrent malignant effusions requiring indwelling pleural catheter, use 32557 (image-guided pleural catheter, 3.04 wRVU), not 32554/32555. Document the reason for indwelling catheter vs. repeat aspiration.