Pulmonology Coding Alert

One example illustrates that you don't always have to append modifier -51 with 31624

To report bronchoscopy procedures properly, you must consider where (that is, multiple lobes or locations) the procedures occurred and what method the pulmonologist used for the cell washing and biopsies.

A common problem that coders run into is overlooking all aspects of the procedure the pulmonologist completed (that is, the biopsy locations, in addition to the number of biopsies he obtained and the techniques he used to obtain them). You also need to avoid the biggest pitfall for coders and make sure the payers won't consider your bronchoscopy bundled into another procedure, says Karen Dorval, CPC, billing and coding specialist with the Pneumos Clinic in Bismark, N.D. Every detail counts.

Use the following example, provided by Vicky O'Neil, CPC, CCS-P, internal medicine compliance coordinator in St. Louis, Mo., to test whether you can accurately apply 31628 and the accompanying diagnosis codes.

Sample Report for Bronchoscopy With Biopsies

Here's a typical report that illustrates the common details that you can't afford to miss:

History: The patient is a 42-year-old male with a history of chronic obstructive pulmonary disease (COPD). The patient underwent a post-bilateral lung transplant six months before the current procedure due to the COPD diagnosis.

He presents with a 10-day history of increased shortness of breath and previously noted airway stenosis post-transplant.

Preprocedure diagnosis: Airway stenosis and shortness of breath status post bilateral lung transplant

Premedications: 0.4 mg Atropine IM

Anesthesia/Sedations: 20 ml of 1% Lidocaine topical, 6 ml of 2% Lidocaine topical, 10 mg versed intravenous push (IVP), and 150 mg Fentanyl IVP.

Procedure: The pulmonologist advanced the bronchoscope past the vocal cords and over the #8 endotracheal tube (ETT). He then passed the scope through both anastamoses and removed thick secretions from the patient's bilateral airways. He next observed that secretions were most abundant in left upper lobe and left lower lobe.

The pulmonologist then completed a bronchial alveolar lavage (BAL) of the lateral subsegmental right lower lobe. He instilled 100 ml of saline into the patient's right lower lobe, and the operator received a return of 35 ml of fluid. The pulmonologist then completed transbronchial biopsies x 13 in the right lower lobe.
 
The patient tolerated the procedure well without any immediate complications. The pulmonologist confirmed that the patient did not show signs of pneumothorax using fluoroscopy.

Estimated blood loss: 20 ml.

Coding Solution Hinges on Right Lobe Procedures

You should report codes 996.84 (Complications of transplanted lung), status/post lung transplant (V42.6), 519.1 (Stenosis of bronchus or trachea), and 786.0(Shortness of breath) to cover every detail of the patient's condition during the procedure.

Although the pulmonologist obtained multiple transbronchial biopsies, the pulmonologist took all of the biopsies from the right lower lobe. Therefore, you should only report 31628 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy[s], single lobe) for the lung biopsies obtained during bronchoscopy, O'Neil says.
 
Note: Be sure to list the codes in RVU order - highest first - which is 31628 in this case. You should also report 31624 (... with bronchial alveolar lavage) for the BAL as the second highest procedure, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy and Critical Care at Emory University School of Medicine in Atlanta.

Bonus: Medicare does not require you to append modifier -51 (Multiple procedures) on 31624 because carriers pay for these services through the multiple endoscopy payment rules, though you should check with private payers to confirm whether they require it to ensure correct payment, O'Neil says.