CPT code 32555 coded sample report

Ultrasound guided right thoracentesis

Indication: Pleural effusion

Findings: Written informed consent was obtained from the patient after  explanation of risks, benefits and alternatives. Limited ultrasound scanning over the back for localization of the right pleural effusion. Overlying skin posteriorly was marked with ultrasound and then sterilely prepped and draped. Local anesthesia with 1% lidocaine. A 6 French safe T centesis catheter was then entered into the pleural space and 800 cc of amber fluid were obtained utilizing negative suction bottles. Catheter was removed. There were no immediate complications. Postprocedural scanning showed a small amount of residual fluid. Therapeutic only.

IMPRESSION:
Ultrasound guided thoracentesis with 800 cc of amber fluid obtained.

CPT code 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance

 

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