Pulmonology Coding Alert

Don't even think about appending modifier 51 to 38746 -- here's why.

Rarely do bronchoscopy and thoracotomy go together in a claim as separate procedures.

Since 2004, the Correct Coding Initiative (CCI) has bundled bronchoscopy and thoracotomy codes, and only by appending modifier 59 (Distinct procedural service) to the bronchoscopy code could you bill them separately " that is, if both codes are appropriate to report.

But not so fast. You should watch out for cases when 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) and 321xx (Thoracotomy, major) could work handin hand as two separate elements.

A scenario which may support bronchoscopy and thoracotomy complementing each other is when a thoracic surgeon performs a diagnostic bronchoscopy prior to a thoracotomy and, based upon the results of the bronchoscopy, undertakes thoracic surgery.

Learn more about reporting a bronchoscopy when the thoracic surgeon performs a thoracotomy with the following case study.

Examine Preoperative Details

A thoracic surgeon examines a 54-year-old long-term smoker who has hemoptysis (786.3) and dizziness (780.4). A chest x-ray demonstrates a right hilar fullness. A computed tomography image (CT scan) reveals a right hilar mass abutting the superior vena cava and aorta with possible right upper lobe infiltrate associated with multiple lymph nodes. The thoracic surgeon with the patient's input decides to perform a biopsy to remove the mass.

Read Between the Lines of Biopsy Procedure Note

In the operating room, the anesthesiologist places a double lumen endotracheal tube into the trachea. The thoracic surgeon performs fiberoptic bronchoscopy with a pediatric bronchoscope to check the position of the double lumen tube. The nurse anesthetist under the aegis of the anesthesiologist places a Foley catheter, administers anesthesia, and places a radial artery catheter for postoperative management.

The thoracic surgeon then makes a posterolateral thoracotomy incision and develops subcutaneous flaps. He carefully enters the right pleural space through the sixth intercostal space. He discontinues ventilation from the right lung and then manually palpates the lung.

In the proximal portion of the right upper lobe, the physician palpates a mass. The physician performs a needle biopsy and sends the specimen to pathology.The physician exposes the hilum and samples multiple lymph nodes in the right paratracheal, subazygos and posterior hilar areas. All of these specimens go to pathology for frozen sections. All return with the diagnosis of granulomatous inflammation (289.1) and no malignancy.

The physician then excises the mass. After that, the physician sends all of the tissue separately for cultures.

He oversews the incisional site with 4-0 Prolene, places chest tubes, reapproximates the ribs, and closes the wound.

Ready With the Solution? Do It Step-by-Step

Step 1: Start by referring back to the fiberoptic bronchoscopy mentioned in the report, says Anne-Marie Miklos, CPC, coding consultant in Winter Springs, Fla. The procedure may appear on the report loud and clear, but the physician performs the bronchoscopy to determine if the double lumen endotracheal tube is in the correct position, and not to determine surgical resectability. In this case, although necessary for patient safety, you should not code the bronchoscopy procedure.

Step 2: Note that the physician takes the needle biopsies from the right upper lung and sends the biopsies for pathology. He also takes an incisional biopsy. For this procedure, you should bill 32140 (Thoracotomy, major; with cyst[s] removal, with or without a pleural procedure) or 32151 (Thoracotomy, major; with removal of intrapulmonary foreign body), depending on the extent of the procedure detail and location of mass, according to Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Why: It includes a major thoracotomy incision with needle biopsy (one or multiple) or incision using a scalpel or scissors.

Step 3: Don't forget to report 289.1 (Granulomatous lymphadenitis) for the diagnosis. Remember reading about the physician removing multiple lymph nodes from the right paratracheal, subazygos areas and posterior hilar areas? Then you should also include 38746 (Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes [list separately in addition to code for primary procedure]) with 289.1.

Caution: CPT 38746 is an add-on code -- additional intraservice work associated with the primary service/procedure.

Don't even think about appending modifier 51 (Multiple procedures) to this code because as an add-on, 38746's reimbursement should not be reduced.

Tip: Appending modifier 59 in the above scenario does not apply since you should not be reporting a bronchoscopy code in the first place. However, if the patient developed hemoptysis  immediately post operatively and was bronchoscoped to find the source of the bleeding, you could code 31622 with modifier 59 since the bronchoscopy was separate from the surgical procedure.