Internal Medicine Coding Alert

Question: Recently my internist (who specializes in pulmonology) did a bronchoscopy with left-upper lobe and left-lower lobe endobronchial biopsies, left-lower lobe transbronchial biopsy, left-upper lobe brushing, left-upper lobe washing and left-lower lobe washing. How should this be coded? Is 31628 x 1, 31625-51 x 2, 31623 (with or without modifier) and 31624 (with or without modifier) x 2 correct?

Iowa Subscriber

 Answer: The correct code for bronchoscopy with left-upper lobe and left-lower lobe endobronchial biopsies and left lower lobe transbronchial biopsy is 31628, (bronchoscopy [rigid or flexible]; with transbronchial lung biopsy, with or without fluoroscopic guidance). Code 31628 can be billed only once even though multiple bronchial sites were biopsied.
 
According to the national Correct Coding Initiative ,  31625 (bronchoscopy [rigid or flexible]; with biopsy) is a component of 31628 and cannot be billed separately as this would be unbundling the 31628 procedure. The biopsies are included in 31628. Code 31628 would be billed as the primary procedure because it has the highest relative value unit (RVU). The transitional nonfacility total RVU for 31628 is 7.44.
 
Your question indicated the surgeon performed a left-upper lobe brushing. The correct CPT code for this procedure is 31623 (bronchoscopy [rigid or flexible]; with brushing or protected brushings). Because it was a secondary procedure, append modifier -51 (multiple procedures). Although a separate procedure, washings are part of a bronchoscopy (i.e., 31622, bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) and cannot be billed more than once.
 
Your question indicated a left-upper and left-lower lobe washing. If the operative report indicates washings, these cannot be billed separately and are part of 31628. If the bronchoscopy was performed with bronchial alveolar lavage, that procedure should be billed with 31628 and 31624 appending modifier -51. Code 31624-51 (... with bronchial alveolar lavage) should be billed as the third procedure because it has the lowest RVUs. The transitional nonfacility total RVU for 31624 is 5.94. However, your question did not indicate if bronchial alveolar was performed. You should review the operative report and talk with the attending physician.
 
If the bronchoscopy with biopsies was performed in the left lung, upper and lower lobes, it is inappropriate to bill these procedures twice (i.e., once for the left-upper lobe and once for the left-lower lobe). However, if a separate bronchoscopy with biopsies was performed on the right lung, that procedure would be reported with 31628 with modifier -59 (distinct procedural service) attached to indicate it was a distinct, independent procedure performed on a separate anatomic site. CPT 2001, under the heading Endoscopy, states, For endoscopy procedures, code appropriate endoscopy of each anatomic site examined.