Pulmonology Coding Alert

Scrutinize the note for incision, biopsy details

Bronchoscopies and 32100 (Thoracotomy ...)don't always go hand-in-hand. Unless a diagnostic bronchoscopy unveils a problem requiring surgery, you can't bill 31622 for the bronchoscopy with other procedures the physician performs through a thoracotomy incision, such as 32100, for a thoracotomy with exploration and biopsy.

Typical scenario: A physician performs diagnostic bronchoscopy. Based on the results of the bronchoscopy, he recommends thoracic surgery when the scope identifies a problem that requires a thoracic procedure.

Look at the following case example provided by Anne-Marie Miklos, CPC, coding consultant in Winter Springs, Fla., to learn more about reporting a bronchoscopy when the physician performs a thoracotomy.

Step 1: Review the Preliminary Details

A 54-year-old long-term smoker with hemoptysis (786.3) and dizziness (780.4) comes to your surgical practice. Results from a chest x-ray indicate right hilar fullness. A computed tomography image (CT scan) shows a right hilar mass abutting the superior vena cava and aorta with possible right upper lobe infiltrate with multiple lymph nodes. The physician decides to perform a biopsy to remove the mass.

Step 2: Look for Biopsy Details in the Procedure Note

In the operating room, the surgeon places a double lumen endotracheal tube and performs fiberoptic bronchoscopy to check the position of the endotracheal tube in the left mainstem bronchus. The nurse anesthetist places Foley catheters, administers anesthesia, and places a radial artery catheter for postoperative blood gas management.

The physician then makes a posterolateral thoracotomy incision and develops subcutaneous flaps. He identifies an auscultatory triangle and enters the right pleural space through the sixth intercostal space. He takes the right lung out of the ventilatory circuit and then manually palpates the lung.

In the proximal portion of the right upper lobe, the physician palpates an inflammatory mass. The physician performs a needle biopsy and sends the specimen to pathology. The physician excises the hilum and identifies multiple adenopathies in the right paratracheal, subazygos and posterior hilar areas. All of these specimens go to pathology for frozen sections, and all return with the diagnosis of inflammatory fibrosis (515).

Consequently, the physician incises the mass and carries out an incisional biopsy. Then, the physician sends all of the tissue separately for cultures.

He oversews the incisional biopsy with 4-0 Prolene, places chest tubes, reapproximates the ribs, and closes the auscultatory triangle.

Step 3: Here's What You Should Report

You should begin with the fiberoptic bronchoscopy identified in the report, Miklos says. The physician clearly says he performed the bronchoscopy, but the reason for doing so is to determine if the endotracheal tube is in the correct position, Miklos says.

Hint: In this case, you should not code the bronchoscopy (31622, Bronchoscopy, rigid or flexible ...; diagnostic, with or without cell washing [separate procedure]) because the physician does not perform the bronchoscopy to determine surgical resectability, Miklos says.

Next, the physician takes the needle biopsies from the right upper lung and sends the biopsies for pathology. He also takes an incisional biopsy.

Don't miss: You should report 32100 (Thoracotomy, major; with exploration and biopsy), Miklos says, because it includes a major thoracotomy incision with needle biopsy (one or multiple) or incision using a scalpel or scissors. You should also report 515 (Postinflammatory pulmonary fibrosis) and 305.1 (Tobacco use disorder).

And, the physician removes multiple lymph nodes from the right paratracheal, subazygos areas and posterior hilar areas. Therefore, you should also report +38746 (Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes [list separately in addition to code for primary procedure]) with 515 and 305.1.

Warning: You should not append modifier -51 (Multiple procedures) to 38746 because CPT indicates that this is an add-on code and reimbursement should not be reduced, which appending -51 would do.

Extra: Don't forget to check your latest National Correct Coding Initiative (NCCI) edits when you come across these two codes.

According to version 10.2, which went into effect on April 1, 2004, NCCI bundles the codes for bronchoscopies and thoracotomies. You can only bill them separately if you append modifier -59 (Distinct procedural service) to the bronchoscopy code, says Roger Hettinger, CPC, CMC, CCS-P, coding specialist at the Sioux Valley Clinic in Sioux Falls, S.D.

You should not append modifier -59 in the scenario above because the bronchoscopy code is not the appropriate code to report.