Cracking the Code
Coding Diagnostic vs Therapeutic Procedures
The main factor when considering whether a procedure is diagnostic or therapeutic is to determine the objective of the procedure. If the main objective is to establish a diagnosis for the patient prior to starting any kind of treatment, then it is considered to be a diagnostic procedure. If a diagnosis is already established and a procedure is completed in order to eradicate a problem, then it is considered to be a therapeutic procedure. For drainage root operations, the ICD-10-PCS guidelines state that if a diagnostic procedure is followed by a more definitive procedure (therapeutic) then both the diagnostic and more definitive treatment are coded.
Q: A patient comes in for a biopsy of their left pleural cavity via thoracentesis. During the same encounter, the physician also performs a therapeutic thoracentesis from the right side of the patient’s chest.
A: 0W9B3ZX, drainage of left pleural cavity, percutaneous, diagnostic 0W993ZX, drainage of right pleural cavity, percutaneous
Reference: ICD-10-PCS Official Guidelines Section B3.4: biopsy followed by more definitive treatment