Pulmonology Coding Alert

A pulmonary physician who has performed a lung lavage may write in his or her notes just the word lavage. A coder must know that 32997 (total lung lavage [unilateral]) is very different from 31624 (bronchoscopy [rigid or flexible]; with bronchial alveolar lavage) and make sure to use the correct code to avoid fraud and ensure proper payment.

Because both procedures begin with a bronchoscope and may be performed for similar reasons, many coders may be confused whether to use 32997 or 31624 when they see lavage in the pulmonologists notes. But total lung lavage is a complex procedure performed in the operating room. The physician actually has to drown the patients lung, says Carol Pohlig, BSN, RN, CPC, reimbursement analyst at the Hospital of the University of Pennsylvanias department of medicine in Philadelphia.

Cheryl Odquist, CPC, a reimbursement and compliance consultant at Codeology, a reimbursement and compliance consulting firm in San Diego, underscores the seriousness of total lung lavage. Its important to recognize that total lung lavage is a unilateral procedure, because if both lungs were to be lavaged, the patient would drown.

During the procedure, a double lumen catheter is introduced orally. The catheter is placed so that it separates the two main bronchi the physician now has access to both lungs. One side is ventilated while the other is lavaged.

The lung to be lavaged is instilled with saline, which is equal to the amount of oxygen within that lung. General anesthesia is used with appropriate monitoring devices. Complete degassing is accomplished by instilling saline into functional residual lung capacity to prevent air pockets. Total volume instilled is usually about 15.25 liters. Once filled, the lung is drained via suction or gravity. The process is repeated several times. Theres no incision or puncture of the pleural cavity.

Identifying Bronchial Alveolar Lavage

Pohlig contrasts the more common and less invasive procedure involved in bronchial alveolar lavage. Its done during bronchoscopy, through a bronchoscope, she says.

Odquist elaborates: Bronchial alveolar lavage requires the use of a bronchoscope with fiberoptic camera. Bronchoscopy is inherently a bilateral procedure. The scope is introduced via the nasal or oral cavity. Saline is instilled in sequentially numbered 20- milliliter aliquot increments, each of which is aspirated before the other begins.

Nancy DeMarco Lamare, CPC, CCS-P, a multispecialty coder for Central Maine Clinical Associates in Lewiston, in Monmouth, Maine, describes the difference in a way that highlights what the two procedures have in common. Both codes begin with a fiberoptic or rigid bronchoscope being fed through the nasal or oral cavity into an anesthetized airway.

The purpose of the two procedures can also be similar, even though the procedures themselves are different. In each case, the physician may be concerned about diseases such as cancer.

For bronchial alveolar lavage, Lamare says, The scope is advanced to the bronchus where the tissues of the bronchial alveoli are irrigated with a saline solution, then suctioned out. The solution containing the cells is sent to pathology to diagnose certain diseases such as cancer. For 32997, the scope is advanced to the lung, where the lung tissues are irrigated with the saline solution, then suctioned out. The solution containing the cells is sent to pathology to diagnose certain diseases such as cancer.

Concerning the possibility for confusion between the two codes, Odquist says, I dont doubt that this is still an issue, since there are a lot of new coders and the CPT book doesnt clarify the scope. Coders should request more detailed information from the pulmonologists if theyre asked to code a procedure simply described as lavage.