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* From the Interventional Pulmonary Program (Dr. Haas), Jefferson Medical College of Thomas Jefferson University, Pulmonary and Critical Care Medicine; and Interventional Pulmonary Program (Drs. Sterman and Musani), Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
Correspondence to: Andrew R. Haas, MD, PhD, Assistant Professor of Medicine, Director, Interventional Pulmonary Program, Jefferson Medical College of Thomas Jefferson University, Pulmonary and Critical Care Medicine, 834 Walnut St, Sixth Floor, Philadelphia, PA 19107; e-mail: andrew.haas{at}jefferson.edu
Abstract
Malignant pleural effusions (MPEs) are a troublesome and debilitating complication of advanced malignancies, with > 150,000 cases in the United States each year. The standard management approach begins with a diagnostic and/or therapeutic thoracentesis. Should the MPE recur, a more definitive management strategy is often undertaken with several approaches available to the chest physician or surgeon. These options include repeat thoracentesis, tube thoracostomy with chemical pleurodesis, placement of an indwelling cuffed, tunneled pleural catheter with or without pleurodesis, or medical pleuroscopy or video-assisted thoracoscopic surgery with pleurodesis. Each approach has unique advantages, disadvantages, and likelihood of successful symptom relief and pleurodesis. This article will provide a general review of MPE management strategies including information concerning coding, billing, documentation, and a decision approach among these various methods.
Key Words: malignant pleural effusion • pleural catheter • pleurodesis • practice management • thoracoscopy
Malignant pleural effusions (MPEs) can be a complication of virtually any malignancy. Lung and breast cancer account for the majority of MPEs, with lymphoma, ovarian cancer, GI malignancies, mesothelioma, and other malignancies accounting for the remainder.12 Except for breast cancer, MPE portends a poor prognosis, with a mean survival of < 6 months.3 Quality of life with MPE is often compromised due to debilitating symptoms like dyspnea, cough, orthopnea, and/or chest pain or pressure. On occasion, MPE can be managed by treating the underlying malignancy with contemporary antineoplastic agents and/or radiation therapy. Unfortunately, in the majority of cases, the MPE either does not resolve or recurs after initial drainage.
There are several approaches to MPE management, with the objective of each procedure to drain the pleural space and to relieve respiratory symptoms. Initial drainage customarily occurs with standard thoracentesis to confirm the presence of malignant pleural disease and to provide symptomatic relief. If the MPE recurs, several approaches can be taken for further control: repeat thoracentesis, placement of an indwelling, cuffed, tunneled pleural catheter (ICTPC), tube thoracostomy with pleurodesis, or medical pleuroscopy or video-assisted thoracoscopic surgery (VATS) with pleurodesis. Each of these approaches has varying degrees of success achieving pleurodesis with VATS or medical pleuroscopy with talc insufflation or chest tube with talc slurry being the most successful (Table 1 ).2456
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Recurrent MPE can be managed with repeat thoracentesis; however, this approach does not prevent the reaccumulation of pleural fluid and requires repeated procedures over an interval dependent on the rate of fluid accumulation. Therefore, this approach would not be recommended except in patients refusing definitive procedures or in patients with advanced disease and life expectancies measured in days to weeks who may have significant morbidity from more invasive procedures. The possible complications associated with thoracentesis include pneumothorax, bleeding, infection, or much less commonly hemothorax, hemoptysis, or tracking of tumor into the thoracentesis site.
ICTPC
In June 1997, the Food and Drug Administration approved an ICTPC with a one-way drainage valve to be used in patients with MPE (Fig 1 ). This ICTPC is designed for outpatient insertion in a standard procedure or endoscopy room with conscious sedation and cardiopulmonary monitoring. It is introduced through a subcutaneous tunnel to minimize infection risk and to secure the catheter. The ICTPC can be accessed and drained with a negative pressure drainage bottle at home. Other percutaneous pleural catheters are available for drainage of the pleural space, but they do not utilize a subcutaneous tunnel. The possible complications associated with insertion of ICTPCs are pneumothorax, bleeding, and chest wall hematoma at the insertion site. Furthermore, due to their chronic indwelling nature, infection, catheter clogging, and much less commonly, tracking of tumor into the subcutaneous tunnel can occur.
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Standard Tube Thoracostomy, Medical Pleuroscopy, or VATS With Pleurodesis
Standard tube thoracostomy can be performed at the bedside with local anesthesia if necessary; however, for patient comfort and safety, the procedure is best performed where conscious sedation and cardiopulmonary monitoring can occur. Medical pleuroscopy, often performed by pulmonologists, entails insertion of a pleuroscope through a single port into the pleural space, evacuation of pleural fluid, biopsy of parietal pleura lesions, and insufflation of talc into the pleural space.17 Medical pleuroscopy is most often performed under conscious sedation with a spontaneously breathing patient. In contrast, although the same components of the procedure are performed during VATS, it is performed under general anesthesia with a double-lumen endotracheal tube to allow for single-lung ventilation. This approach allows better visualization of the entire parietal and visceral pleurae, and with the use of two to three surgical ports a surgeon can manipulate the lung to perform lung biopsies if necessary.
The objective of these three modalities is to relieve patient symptoms, to achieve pleural apposition, and to prevent fluid reaccumulation by creating pleural symphysis through the use of a sclerosing agent. Talc pleurodesis has been shown in clinical trials to be superior to other sclerosing agents161819202122 such as bleomycin, tetracycline, or doxycycline. Whether talc is administered via slurry through a chest tube or via insufflation during pleuroscopy/VATS does not appear to alter the effectiveness.6 In the largest randomized controlled trial4 comparing talc insufflation with talc slurry, there was no statistically significant difference in pleurodesis at 30 days with either approach (78% vs 71%, respectively). However, subgroup analysis did demonstrate that MPEs from either lung or breast cancer had greater pleurodesis success with talc insufflation than slurry (82% vs 67%, respectively). No clinical trial has compared medical pleuroscopy with VATS pleurodesis.
The complications associated with these procedures are bleeding, infection, pneumothorax, and pain related to the chest tube and sclerosing agent. The major complication of talc pleurodesis is the potential development of noncardiogenic pulmonary edema, which can be fatal.23242526 In fact, in the aforementioned randomized trial,4 respiratory failure developed in 4% (talc slurry) to 8% (thoracoscopic talc insufflation) of patients following talc pleurodesis. Although talc continues to be the most commonly used sclerosing agent due to its low cost and availability, its safety compared to other agents continues to be vigorously debated by some experts.27
Practice Management
Precertification
Thoracentesis can be performed in the outpatient setting without precertification because it is considered a simple office procedure. The ICTPC requires drainage systems and home nurse association visits. Therefore, precertification from both the insurance and home care providers prior to insertion of the ICTPC is vital to prevent undue personal expense to the patient should these items not be covered. Since standard tube thoracostomy, medical pleuroscopy, and VATS are inpatient procedures that require hospitalization, usual precertification steps must be taken if the patient has an outpatient evaluation and is scheduled to have the procedure performed as a same day hospital admission.
Coding
Table 2
lists the options available for management of MPE with their respective American Medical Association current procedural terminology (CPT) code and professional reimbursement.28 There are several coding issues to address specifically. Code 32000 refers to standard thoracentesis performed with the placement of a needle into the pleural space to aspirate a small volume of pleural fluid for diagnostic purposes. If thoracentesis entails advancing a small-bore catheter temporarily into the pleural space for diagnostic and therapeutic fluid aspiration, code 32002 should be utilized. Code 32020 (tube thoracostomy) denotes insertion of a tube into the pleural space to provide ongoing drainage, typically for several days. If bedside ultrasound is performed by the physician to localize fluid for aspiration (codes 32000 or 32002), CPT code 76942 is appropriate. CPT code 75989 applies if ultrasound guides placement for tube thoracostomy (code 32020). When ultrasound is performed in a facility-based setting, the physician reports codes 76942 and 75989 with modifier – 26 indicating professional interpretation. The facility reports the technical component. In a nonfacility setting where the physician owns the imaging equipment, report the global service without modifier – 26 (eg, 76942, 75989).29
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For medical pleuroscopy and VATS, code 32650 supercedes codes 32601 and 32602. In other words, if pleurodesis is performed, code 32650 applies whether or not biopsies are performed as codes 32601 and 32602 are bundled into 32650. If pleurodesis is not performed, but pleural biopsies are performed, code 32602 applies and reimbursement for inspection of the pleural space (code 32601) is bundled into 32602.
Chemical pleurodesis (CPT code 32005) is an integral component of MPE management. Code 32005 is a separate code when instilled through a chest tube (code 32020) but is bundled with codes 32019 and 32650 and cannot be coded separately with these procedures.
Reimbursement
Table 1 delineates the professional reimbursement for each procedure previously discussed. These values represent the Medicare reimbursement for the Greater Philadelphia Metropolitan area. Reimbursement for specific geographic areas can be obtained from individual insurance providers or at the Centers for Medicare and Medicaid Services Web site (http://www.cms.hhs.gov/apps/pfslookup/).30
Documentation
Standard documentation principles apply to all MPE management strategies. An operative or procedure report should provide details of the procedure, and this report is placed into the patient’s medical record. If ultrasound is used for the procedure, this fact must be clearly stated in the procedure report to receive reimbursement. Ideally ultrasonic images should be included in the medical record with a physical description of depths and structures. For physicians at teaching hospitals, the attending physician should provide a personal attestation to their presence and participation during the "key and critical portions" of the procedure if the dictation is performed by a training physician.
Which Approach Is Best for Your Patient With MPE?
There is no one correct answer for which strategy is best for MPE management. Each approach will address respiratory symptoms; however, the patient’s comorbidities, disease stage, ongoing therapy, life expectancy, as well as the practical aspect and available expertise for each strategy must all be considered. For frail patients with advanced disease and poor performance status whose life expectancy is estimated at weeks to several months, the least invasive approach that minimizes inpatient hospitalization and patient discomfort would be ideal. In these circumstances, repeat thoracentesis or placement of an ICTPC can effectively manage symptoms. In fact, de Campos et al31 reported that malnourished patients with advanced malignancy and Karnofsky performance scale scores 
40 should be excluded from thoracoscopic talc insufflation due to significant morbidity in these debilitated patients.
For patients with good performance status, each method will address symptoms, but repeat thoracentesis is clearly the least desirable method because it will not prevent fluid reaccumulation. Therefore, the ICTPC, tube thoracostomy with talc slurry, or thoracoscopic talc insufflation are all potential options. After a candid discussion of these options and the associated risks and benefits, some patients desire to avoid surgical intervention or hospitalization. In these patients, an ICTPC may be the best option. In patients who do not desire frequent home visits or a chronic indwelling catheter, either tube thoracostomy with talc slurry or thoracoscopic talc insufflation would be better options. With the data from the study by Dresler et al,4 patients with lung or breast cancer may have the best pleurodesis outcome with thoracoscopic talc insufflation. At this time, randomized trials comparing the ICTPC with either tube thoracostomy or thoracoscopic talc insufflation in terms of pleurodesis rate, patient satisfaction, quality of life measures, and complications have not been conducted. These trials would better delineate the role of each of these modalities for MPE management.
Conclusion
MPEs are a frequently encountered problem by the chest physician or surgeon. There are several MPE management strategies, and the procedure of choice depends on several factors such as patient age, disease stage, performance status, life expectancy, comorbidities, local expertise, and patient autonomy to make an informed decision. Each procedure has good success at managing respiratory symptoms, but relevant complications and pleurodesis rates vary. If all options are presented to the patient in an objective manner and clearly discussed, a mutual decision can be achieved with not only the best outcome in terms of managing pulmonary symptoms, but also optimizing quality of life.
Footnotes
Abbreviations: CPT = current procedural terminology; ICTPC = indwelling, cuffed, tunneled, pleural catheter; MPE = malignant pleural effusion; VATS = video-assisted thoracoscopic surgery
Dr. Haas and Dr. Sterman have no financial conflicts of interest to disclose. Dr. Musani is a member of the Speakers Bureau for Pleurx catheter (Denver BioMedical, a Subsidiary of Cardinal Health; Golden, CO).
Received for publication July 13, 2006. Accepted for publication February 10, 2007.
References
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