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 [...]