A 40-year-old male patient with AIDS is on a ventilator due to dyspnea; pneumonia is suspected; thoracoscopy is performed and the right lung is biopsied; Pneumocystis carinii pneumonia is diagnosed. What are the correct procedure and diagnosis codes?

A 40-year-old male patient with AIDS is on a ventilator due to dyspnea; pneumonia is suspected; thoracoscopy is performed and the right lung is biopsied; Pneumocystis carinii pneumonia is diagnosed. What are the correct procedure and diagnosis codes?

• A. 32608,B20,B59
• B. 32604,B20,B58
• C. 32608,B23,B59
• D. 32610,B20,B58

Answer: (A)

The key idea is to match the procedure exactly to what was done and to capture both the underlying condition and the infection when both are documented. The procedure described is thoracoscopy with biopsy of the lung (the right lung was biopsied during the thoracoscopy). The CPT code that fits this scenario is 32608, which represents thoracoscopy with biopsy of the lung. Other thoracoscopy codes would be used for different biopsy sites or for diagnostic thoracoscopy without a lung biopsy, so they don’t fit the described operation. For the diagnoses, Pneumocystis jirovecii pneumonia is coded as B59. The patient also has AIDS, so the underlying condition is HIV disease coded as B20. Coding both reflects that the opportunistic infection occurred in the context of HIV/AIDS, which is standard when both are documented. Thus, the best combination is the lung biopsy thoracoscopy code (32608) with the diagnoses B20 (HIV disease) and B59 (Pneumocystis pneumonia).

The key idea is to match the procedure exactly to what was done and to capture both the underlying condition and the infection when both are documented.

The procedure described is thoracoscopy with biopsy of the lung (the right lung was biopsied during the thoracoscopy). The CPT code that fits this scenario is 32608, which represents thoracoscopy with biopsy of the lung. Other thoracoscopy codes would be used for different biopsy sites or for diagnostic thoracoscopy without a lung biopsy, so they don’t fit the described operation.

For the diagnoses, Pneumocystis jirovecii pneumonia is coded as B59. The patient also has AIDS, so the underlying condition is HIV disease coded as B20. Coding both reflects that the opportunistic infection occurred in the context of HIV/AIDS, which is standard when both are documented.

Thus, the best combination is the lung biopsy thoracoscopy code (32608) with the diagnoses B20 (HIV disease) and B59 (Pneumocystis pneumonia).