Paracentesis
Ultrasound-guided paracentesis, [diagnostic / therapeutic large-volume]
[New-onset / Worsening] ascites due to [cirrhosis / malignancy] requiring [diagnostic paracentesis to evaluate for spontaneous bacterial peritonitis / therapeutic large-volume paracentesis for symptomatic relief].
Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives.
[***, MD/DO]
Local: [X] mL 1% lidocaine without epinephrine
Ultrasound showed a [large / moderate] pocket of free abdominal fluid in the [left lower quadrant / right lower quadrant / suprapubic region] measuring [X] cm in depth. [X] mL of [straw-colored / serosanguineous / cloudy / bloody / milky] ascitic fluid was removed.
A time-out was completed confirming the patient, procedure, and site. The patient was placed supine with the head of the bed elevated slightly. Ultrasound was used to select the puncture site at the largest fluid pocket, clear of bowel, bladder, and the inferior epigastric vessels. An ultrasound image was saved documenting the fluid pocket and planned puncture site.
The skin was prepped with chlorhexidine and draped in sterile fashion. The skin and subcutaneous tissue were infiltrated with [X] mL of 1% lidocaine using a Z-track technique. A [thoracentesis needle / 15-gauge paracentesis needle / 5 Fr pigtail catheter] was advanced through the anesthetized tract under ultrasound guidance with gentle aspiration. Entry into the peritoneal cavity was confirmed by free return of ascitic fluid.
Fluid was [aspirated by syringe for diagnostic studies / drained by vacuum bottles / drained by gravity]. Fluid for culture was inoculated directly into blood culture bottles at the bedside. The [needle / catheter] was removed, pressure was applied, and the puncture site was dry without fluid leak.
None
Ascitic fluid for cell count with differential, total protein, albumin, LDH, Gram stain and culture in blood culture bottles[, cytology][, amylase][, triglycerides][, glucose]
None
The patient tolerated the procedure well and is being monitored after the procedure. [Albumin [X] g [was administered / was ordered] for large-volume paracentesis.] Ascitic fluid results will be followed[, with the serum-ascites albumin gradient calculated using a serum albumin of [X] g/dL].
Epic SmartPhrase Version
PROCEDURE: Ultrasound-guided paracentesis, [diagnostic / therapeutic large-volume]
INDICATION: [New-onset / Worsening] ascites due to *** requiring [diagnostic paracentesis to evaluate for SBP / therapeutic large-volume paracentesis for symptomatic relief].
CONSENT: Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
FINDINGS: Ultrasound: *** fluid pocket in ***, depth *** cm. *** mL *** ascitic fluid removed.
PROCEDURE DETAILS:
Time-out completed. Patient supine, HOB slightly elevated. Ultrasound selected site at largest pocket, clear of bowel, bladder, and inferior epigastric vessels. Image saved.
Skin prepped with chlorhexidine and draped in sterile fashion. *** mL 1% lidocaine infiltrated using Z-track technique. *** advanced under ultrasound guidance. Free ascitic fluid return confirmed. Fluid [aspirated by syringe / drained via vacuum bottles / drained by gravity]. Culture fluid inoculated into blood culture bottles at bedside. [Needle / Catheter] removed, pressure held, site dry.
EBL: None
SPECIMENS: Ascitic fluid for cell count, protein, albumin, LDH, Gram stain/culture (blood culture bottles), ***
COMPLICATIONS: None
POST-PROCEDURE PLAN: Tolerated well, monitored. [Albumin *** g given for large-volume paracentesis.] Fluid results to be followed.
Signed: .ME, .MYDEGREE
.TODAYVariants
Diagnostic: SBP Workup
30 mL of ascitic fluid was aspirated for SBP evaluation. Fluid was inoculated directly into aerobic and anaerobic blood culture bottles at the bedside (10 mL each) and an additional aliquot sent for cell count with differential. Results were communicated to the primary team promptly.
Large-Volume Paracentesis with Albumin Infusion
[X] liters of ascitic fluid were removed. Albumin was administered at [8] g per liter of ascites removed. Total albumin infused: [X] g ([X] mL of 25% albumin).
Malignant Ascites
In the setting of known or suspected malignancy, ascitic fluid cytology was sent in addition to standard studies. The ascitic fluid appeared [straw-colored / serosanguineous / bloody]. The primary oncology team was notified.
Charting Tips
- Document ultrasound image confirmation of the fluid pocket, depth, and identification of the inferior epigastric vessels. A permanently saved image is required to bill the imaging-guided service, and ultrasound guidance is not billed separately.
- For large-volume paracentesis (>5 liters), document whether albumin was administered and at what dose. Failure to administer albumin per protocol is a known medicolegal risk and contributes to hepatorenal syndrome.
- Document cell count result if available. Ascitic fluid PMN count over 250 cells/mm3 is diagnostic of SBP and requires immediate empiric antibiotic coverage (typically cefotaxime 2 g IV q8h). Note if results are pending and document the follow-up plan.
- AASLD guidance for paracentesis of more than 5 liters is 6 to 8 g of albumin per liter of ascites removed. Albumin reduces the risk of paracentesis-induced circulatory dysfunction.
- The Z-track technique reduces the risk of ascitic fluid leak from the puncture site.
- Bloody ascitic fluid in a patient with malignancy raises concern for malignant ascites or peritoneal carcinomatosis.
Documentation & Reimbursement Considerations
- Primary service: Report Paracentesis as the primary service when it is the definitive operation performed.
- Paracentesis without imaging guidance (1.21 wRVU, 0-day global) is reported when the procedure is performed by clinical landmark technique.
- Paracentesis with imaging guidance (1.95 wRVU, 0-day global) is reported when real-time ultrasound is used to guide needle placement. Document real-time imaging, a permanent image record, and that guidance was medically necessary (e.g., small effusion, obesity, prior abdominal surgery).
- Do not bill the guided and unguided paracentesis services together. If ultrasound is used, only the imaging-guided service is billed, as the guidance is included.
- 0-day global: no bundled postoperative period. Paracentesis can be billed separately from a same-day E/M if a significant, separately identifiable evaluation is documented, with the appropriate modifier appended to the E/M.
- For large-volume paracentesis (LVP), document volume removed, albumin replacement given, and hemodynamic response. These support medical necessity and are required for diagnostic/therapeutic distinction in payer review.