Outpatient Facility Coding Alert

Question: A vent dependent patient underwent bronchoscopy through an established tract. The findings were mucus plugs in the left lung and a 3mm endobrachial lesion at the start of the right lung’s middle lobe bronchus. Will code 31615 cover this bronchoscopy with the biopsy and mucus plug suction? Or should we use 31623, 31624, or 31625?

Minnesota Subscriber

Answer: Yes, the correct code for a flexible bronchoscopy via a tracheostomy is 31615 (Tracheobronchoscopy through established tracheostomy incision). This code covers elements of both the surgical work (removal of obstructing crusts) and diagnostic bronchoscopy when the same physician performs the procedures.

Keep in mind: You should not report two codes for one procedure. CPT® code 31615 describes a diagnostic tracheobronchoscopy through an established tracheostomy site or incision. Once the procedure involves interventions, a standard bronchoscopy code should be used. Report 31625 for an endobronchial biopsy.

You can only submit code 31623 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushings) if the physician has documented protected brushings. All brushings (single or multiple lobes) are included in this code, so only report it once.

Code 31624 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage) is warranted only in cases where BAL (bronchial alveolar lavage) has been carried out during bronchoscopy.