# NEED CLARIFICATION on biopsy of lymph nodes



## ndriley10 (Jan 18, 2012)

i need clarification on codes 31629 vs. 38505 and using 31633 as an add on code for 31629 It seems as though i should bill 31629 for the RLL mass and 38505 for the lymph node biopsies.  Any thoughts or suggestions on this?


PREOPERATIVE DIAGNOSES:
1.  Right-sided lung mass.
2.  Mediastinal lymphadenopathy.

POSTOPERATIVE DIAGNOSES:
1.  Right-sided lung mass.
2.  Mediastinal lymphadenopathy.

PROCEDURES PERFORMED:
1.  Flexible bronchoscopy.
2.  Endobronchial ultrasound.
3.  Fine needle aspiration of lymph node station 4R.
4.  Fine needle aspiration lymph node station 7.
5.  Fine needle aspiration lymph node station 10R.
6.  Fine needle aspiration right lower lobe mass.

INTRAOPERATIVE FINDINGS:
1.  Bronchoscopy was positive for some mild extrinsic compression noted at the distal bronchus intermedius on the right side.
2.  Endobronchial ultrasound revealed mediastinal lymphadenopathy noted at levels 4R, 7 and 10R.  All of these were biopsied. A mass was noted in the right lower lobe which was also biopsied. The lymph nodes were all negative for malignant cells.  Biopsy of the right lower lobe mass was positive for nonsmall cell lung carcinoma.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in a supine position on the operating room table.  General endotracheal anesthesia was administered and an LMA airway device was placed.  A timeout was called and the patient's name, medical record number and procedures were correctly identified.

A flexible bronchoscope was then introduced in the LMA.  The patient's vocal cords were examined and noted to be functional and moving symmetrically.  The patient's trachea was normal.  The carina was normal.  The left-sided main bronchus and segments were all normal. The right-sided main bronchus was normal.  The right upper lobe bronchus was normal and its segments as well.  The bronchus intermedius was noted to be normal and at its very distal area where the right middle lobe bronchus separates from the right lower lobe, there was noted to be some mild extrinsic compression.  The right superior segment bronchus was definitively compressed and slit like but still open.  The flexible bronchoscope was then removed and the endobronchial ultrasound bronchoscope was placed.

Ultrasound was then used to examine the paratracheal lymph nodes.  There was a large lymph node noted in station 4R and station 7.  These were sampled with endobronchial ultrasound fine needle aspiration needles.  All of these passes returned good lymphoid tissue but no malignant cells were noted.  The endobronchial ultrasound was advanced further and the right hilum was examined with ultrasound.  Multiple 10R lymph nodes were observed.  These were sampled with the fine needle aspiration needles and noted also to have good lymphoid tissue but no malignant cells.  The bronchoscope was positioned carefully in the bronchus intermedius and the right lower lobe mass itself was identified and a fine needle aspiration needle was placed into the right lower lobe mass.  This biopsy confirmed nonsmall cell lung carcinoma.  Additional passes were made to assist in obtaining enough tissue for further diagnostic work.  The endobronchial ultrasound was then removed.  The normal bronchoscope was introduced and the patient's entire endobronchial tree was suctioned clear of blood and secretions.  No hemorrhage was noted at the end of the case.  The bronchoscope was removed.  The patient was awoken from anesthesia and transferred to the recovery room in stable condition.


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## TonyaMichelle (Jan 18, 2012)

*A flexible bronchoscope was then introduced in the LMA. The patient's vocal cords were examined and noted to be functional and moving symmetrically. The patient's trachea was normal. The carina was normal. The left-sided main bronchus and segments were all normal. The right-sided main bronchus was normal. The right upper lobe bronchus was normal and its segments as well. The bronchus intermedius was noted to be normal and at its very distal area where the right middle lobe bronchus separates from the right lower lobe, there was noted to be some mild extrinsic compression. The right superior segment bronchus was definitively compressed and slit like but still open. The flexible bronchoscope was then removed*
*These were sampled with endobronchial ultrasound fine needle aspiration needles. All of these passes returned good lymphoid tissue but no malignant cells were noted. The endobronchial ultrasound was advanced further and the right hilum was examined with ultrasound. *
31629(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed, with tranbronchial needle aspiration biopsy).

* the endobronchial ultrasound bronchoscope was placed.Ultrasound was then used to examine the paratracheal lymph nodes.*
+31620 (Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic interventions. [List separately in addition to code for primary procedure)

* The bronchoscope was positioned carefully in the bronchus intermedius and the right lower lobe mass itself was identified and a fine needle aspiration needle was placed into the right lower lobe mass. This biopsy confirmed nonsmall cell lung carcinoma. Additional passes were made to assist in obtaining enough tissue for further diagnostic work. The endobronchial ultrasound was then removed.*
+31633 (with transbronchial needle aspiration biopy, each additional lobe [List separately in addition to code for primary procedure]).

*Multiple 10R lymph nodes were observed. These were sampled with the fine needle aspiration needles and noted also to have good lymphoid tissue but no malignant cells.*
10022 (Fine needle aspiration with imaging guidance)

I would not use code 38505 because that would be an opened superficial biopsy.


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## egoldrich (Oct 17, 2014)

*Clarification on CPT for FNA of Lymph Nodes - Bronchoscopy*



TonyaMichelle said:


> *A flexible bronchoscope was then introduced in the LMA. The patient's vocal cords were examined and noted to be functional and moving symmetrically. The patient's trachea was normal. The carina was normal. The left-sided main bronchus and segments were all normal. The right-sided main bronchus was normal. The right upper lobe bronchus was normal and its segments as well. The bronchus intermedius was noted to be normal and at its very distal area where the right middle lobe bronchus separates from the right lower lobe, there was noted to be some mild extrinsic compression. The right superior segment bronchus was definitively compressed and slit like but still open. The flexible bronchoscope was then removed*
> *These were sampled with endobronchial ultrasound fine needle aspiration needles. All of these passes returned good lymphoid tissue but no malignant cells were noted. The endobronchial ultrasound was advanced further and the right hilum was examined with ultrasound. *
> 31629(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed, with tranbronchial needle aspiration biopsy).
> 
> ...





I found your reply above very useful. 

Currently, I am being told that I should be coding 31629 for the FNA of the lymph nodes. Do you have reference for the 10022 (which makes sense to me)? Additionally, my understanding was that the ebus (31620) is the imaging guidance for the FNA (10022). Am I mistaken?

Looking forward to your clarification.

Thank you.


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