Pulmonology Coding Alert

If the pulmonologist notes additional bronchoscopies, your reporting should respond accordingly

When your pulmonologist records multiple bronchoscopies, carefully consider modifier 22 when nothing else seems to fit - but always check your documentation for a sufficient justification first.

To justify modifier 22 (Unusual procedural services), your documentation should include details on exactly what services the physician completed that went beyond the usual scope of work included in the code you report, says William J. Conner, MD, founder of Conner Health Clinic, a multispecialty practice in Charlotte, N.C.

For more on reporting multiple bronchoscopies on the same patient on the same day, please refer to the July 2005 Pulmonology Coding Alert for "Case Study, Part I: Avoid Common Coding Snafus for Multiple Bronchoscopies" and the August 2005 Pulmonology Coding Alert for "Case Study, Part II: Consider More Than Just Time for Critical Care Coding."

The Final Operative Report: Success or Not?

In this scenario, the pulmonologist attempts a third bronchoscopy on a patient. (The following operative note was reviewed by Denae M. Merrill, CPC, a pulmonology coder in Saginaw, Mich.)

The pulmonologist noted: left-sided atelectasis, collapsed left lung, and difficult oxygenation. As a result, he performed another bronchoscopy.

Initially, the pulmonologist attempted to use a small bronchoscope and he had a difficult time seeing the lower end of the endotracheal tube. He pushed the bronchoscope between the endotracheal tube and the tracheal wall to see the carina. He was still unable to see the endotracheal tube despite multiple attempts.

Finally, he pulled the endotracheal tube up by a couple of centimeters. At that time, he could see a large mucus plug covering the left main bronchus completely and hiding the carina completely. He was unable to suction the plug with the small bronchoscope.

He then attempted to use a large bronchoscope. The pulmonologist waited for 10 to 15 minutes to receive the large bronchoscope. Once the bronchoscope arrived, the pulmonologist tried to advance it through the endotracheal tube.

Once again, he had the same problem with the endotracheal tube. He squeezed the bronchoscope between the lower end of the trachea and the endotracheal wall. Like before, the pulmonologist could see the carina, but there was a mucus plug in the left main, which was completely occluded. Using saline to assist, he spent the next half hour attempting to vigorously suction out the plug.

He was able to remove some of the mucus plug,  but the plugs appear to be very large and thick, which makes them nearly impossible to suction out completely. After multiple attempts, the pulmonologist ended the procedure.

Once again, there was a significant amount of plugs left in the patient's left main bronchus, which contained significant mucus plugs. The patient's pulse oximetry has improved to 87 percent at this point.

At this time, the patient will undergo chest physiotherapy every four hours. The patient will receive albuterol aerosol treatments every fours hours with Mucomyst. If the patient has oxygen desaturation, the hospital staff will tilt his body onto his right side to enable the blood to flow to that side.

The patient's blood pressure dropped at the end of the procedure because the patient received dialysis and did not receive Levophed. The pulmonologist started the patient on Levophed again, and his blood pressure is slowly improving.

Total critical care time spent for this additional bronchoscopy was 1 hours and 45 minutes.

Consider the Whole Picture for a Coding Solution

As mentioned in Parts I and II of this case study series, because the pulmonologist performs an additional bronchoscopy later in the day to remove the mucus plug, you should report a therapeutic bronchoscopy, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Given the above documentation, you should report 31646 (Bronchoscopy [rigid or flexible]; with therapeutic aspiration of tracheobronchial tree, subsequent).

The pulmonologist performed this bronchoscopy (31646) later on the same day. As discussed in Part II, NCCI considers 31645 (... initial) and 31646 as mutually exclusive codes. This means that a pulmonologist would be unlikely to perform these two services on the same day. NCCI assigns modifier "1" to this code pair, allowing you to report the two services together, when appropriate. For more on these NCCI edits, see the CMS site at www.cms.hhs.gov/physicians/cciedits/default.asp.

In such a case, you should add modifier -59 (Distinct procedural service), Pohlig says, to notify the payer that the pulmonologist performed a distinct service separate from the previous diagnostic bronchoscopy performed on the same day.

Don't miss: You should also append modifier 22 (Unusual procedural services) to 31646. This notifies payers that the pulmonologist would not normally perform multiple procedures on a patient, but due to the "unusual" thickness and large size of this patient's mucus plugs, the pulmonologist was medically justified in making several attempts, which added an exceptional amount of time to the session, Pohlig says.

In addition to the procedure code, you should also report diagnosis code 519.1 (Other diseases of trachea and bronchus, not elsewhere classified) to represent the "mucus plug" identified in the documentation. You may also report 518.0 (Atelectasis) and 799.0 (Difficult oxygenation).

Another reminder: As in Part II, in this scenario, although the patient does appear to meet critical care criteria, the total critical care time represents the time associated with the separately billable bronchoscopy. Therefore, the documentation presented here does not justify reporting critical care codes (99291-99292).