Pulmonology Coding Alert

Find out what word BAL documentation needs.

As a pulmonology coder, you see your fair share of bronchoscopies to code. Knowing the coding fundamentals of these common procedures can help your claims get approved and reimbursed.

But as common as bronchoscopies are, coding them isn’t always straightforward. See if these frequently asked questions help clear up your coding confusion.

How do you Report a Diagnostic Bronchoscopy With Biopsy?

Diagnostic bronchoscopy, coded to 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)), “is our base procedure. The provider goes in, looks around, and might do some cell washings. It’s not a big procedure,” said Jill Young, CEMC, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan during the AAPC webinar, “Pulmonary Medicine - Office and Procedure Billing.”

This procedure is bundled into all the other bronchoscopy procedure codes. The CPT^® code set contains several codes for bronchoscopy procedures where the pulmonologist takes a biopsy or multiple biopsies for testing. The main differences between the codes relate to the anatomical structure being evaluated and the other procedures the provider will perform along with the bronchoscopy:

• 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites)
• 31626 (… with placement of fiducial markers, single or multiple)
• +31627 (… with computer-assisted, image-guided navigation (List separately in addition to code for primary procedure[s]))
• 31628 (… with transbronchial lung biopsy(s), single lobe)
• 31629 (… with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i))
• +31632 (… with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure))
• +31633 (… with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure))

For example, the provider performs a diagnostic bronchoscopy and determines they want to take multiple transbronchial biopsies from the right upper lobe (RUL). You would assign only 31628 to report these procedures since 31622 is bundled into 31628. Also, you’ll notice that 31628’s descriptor includes “biopsy(s), single lobe,” which means you’ll use this code regardless of how many biopsies are captured as long as the procedure occurs in one lobe of the lung.

What Does BAL Documentation Need to Include?

Pulmonologists perform bronchial alveolar lavage (BAL) to evaluate the patient’s airways and alveoli. Physicians use the procedure to diagnose infections, interstitial lung disease, and cancers. The procedure is essentially a liquid biopsy of the distal airways and alveoli, where saline is instilled into the body structures and then removed for testing.

Before you can report 31624 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage) for a BAL procedure, you need to make sure the documentation contains important information.

“The important part of a BAL is that the bronchoscope is wedged. Just putting liquid in there is not a BAL. The bronchoscope is wedged to act as a trap or a stopper. Then as the liquid is pulled out, the provider does a lot of tests on that specific liquid and tracks how much went in and how much went out,” Young said. Typically, the amount of fluid instilled is larger than that used in a typical washing (which is an included feature of a diagnostic bronchoscopy). So, the importance of documenting specific amounts instilled and returned will be key in supporting 31624.

What Fluoroscopic Guidance Code Should I Report With Bronchoscopies?

The CPT^® code set contains three fluoroscopic guidance codes in the radiology section:

• +77001 (Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure))
• +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure))
• +77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure))

However, you won’t include any of these with 31622-31629 if you’re reporting a diagnostic bronchoscopy with fluoroscopic guidance. When you examine the bronchoscopy descriptors, you’ll notice the wording, “including fluoroscopic guidance, when performed,” which means the imaging guidance is inherently included in the procedure — regardless of whether the provider uses it.

Additionally, the Fluoroscopic Guidance code section features a parenthetical note above the codes that instructs you to not report +77001, +77002, or +77003 “for services in which fluoroscopic guidance is included in the descriptor.”