Pulmonology Coding Alert

Closely follow encounter notes to improve reporting accuracy.

Your pulmonologist will often perform a bronchoscopy for a wide variety of indications and one such procedure is bronchial lavage. Understanding the reason for the lavage will set you up for coding success. Read on for some quick tips on tackling lavage procedures with confidence.

Know Procedure Intent

Your pulmonologist does a bronchoalveolar lavage to obtain washings from the lungs and windpipes. "Bronchoalveolar lavage is a procedure done as part of a bronchoscopy in which aliquots of a liquid, generally saline, are instilled through the bronchoscope after the bronchoscope has been wedged into a broncho-pulmonary segment," says Philip Marcus, MD, MPH, FACP, FCCP, Director, Division of Pulmonary Medicine, St. Francis Hospital-The Heart Center, Rosalyn, NY. "Around 30-50 ml of liquid are generally instilled through the bronchoscope channel into the distal airways and lung and then suctioned and collected into a specimen trap. The material obtained is then analyzed, generally for bacteria, fungi, including pneumocystis, and even for cytology."

Your physician may do a bronchoalveolar lavage with a diagnostic intent, though sometimes it may be done as a treatment for the underlying condition. "This procedure is done for diagnostic purposes and is different than a therapeutic bronchoscopy done for removal of mucus plugs that may be causing atelectasis," says Marcus.

Don't Confuse Lavage and Cell Washing

Bronchoalveolar lavage poses a coding challenge as there are two similar codes that look appropriate.

Although 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) and 31624 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage) sound very similar and apt to report for bronchoalveolar lavage, you will need to seek bronchoalveolar lavage in specific in the operative notes to make sure one was performed.

Bronchoalveolar lavage is different in comparison to a cell washing procedure. "A bronchoalveolar lavage implies the instillation of "larger" quantities of saline than for a "simple" bronchial washing, often done as part of a diagnostic bronchoscopy to evaluate for malignancy in which a biopsy, bronchial brushings and washings are collected," says Marcus. "The bronchoalveolar lavage is often done in patients with unexplained infiltrates in which an opportunistic infection is a part of the differential diagnosis."

Exercise Caution With 31622

According to National Correct Coding Initiative (NCCI), you need to avoid 31622 if there is any other code that better determines the procedure your pulmonologist has performed. This means that you should not use 31622 when other bronchoscopy procedures such as bronchoalveolar lavage are done. Instead, you only report 31624.

While bronchoalveolar lavage involves instilling saline into the airways which is then removed through suction and aspiration, a biopsy procedure will involve the removal of tissue samples that will later be sent for laboratory analysis. A biopsy also can involve removal of an entire lesion which is then analyzed in the laboratory. "However, 31624 can be reported in addition to the biopsy procedure, if done," says Marcus. Report all interventions performed in separate areas or on separate lesions, as appropriate. In the case, report 31624 and 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy[s], single or multiple sites).

Identify Total Lavage if Indicated

Another confusion that often crops up when coding for lavage is differentiating between bronchoalveolar lavage and total lung lavage. Often, this confusion arises because your pulmonologist might have mentioned the word "lavage" without going into detail if it is a bronchoalveolar lavage or a total lung lavage. "However, total lung lavage is rarely done these days and is totally different from bronchoalveolar lavage, often done for diagnostic purposes," says Marcus.

Tip: It is easy to identify the right type if you go through the procedure notes in detail. If your pulmonologist has performed a bronchoalveolar lavage, you will see the procedure notes carrying details such as "infused 75 ml of saline and suctioned back 30 ml of fluid". This you should report as 31624.

Look for anesthesia details: If a total lung lavage has been performed, your pulmonologist's procedure notes will show the use of general anesthesia. "Total lung lavage would generally be done using a rigid bronchoscope and has been utilized in the management of pulmonary alveolar proteinosis," says Marcus. Another difference will be that your pulmonologist will use a balanced salt solution instead of the saline. Here, you need to report the procedure as 32997 (Total lung lavage [unilateral]) instead of 31624.