Pulmonology Coding Alert

Today's bronchoscopy is light years away from your father's bronchoscopy and CPT 2010 lets you reflect that change.

"Navigational bronchoscopy allows the physician to see what he's doing more specifically," explained Scott Manaker, MD, PhD, the American College of Chest Physicians (AACP/ATS) representative to the Relative Value Update Committee (RUC) in the "Pulmonary Medicine" session at the AMA CPT and RBRVS Annual Symposium in Chicago. CPT 2010 creates two new codes for you to report this improved technology.

Make sure you code for the procedure's phases and allowed items using these guidelines.

"New code +31627 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, image-guided navigation [List separately in addition to code for primary procedure[s]) for navigational bronchoscopy lets us use your father's bronchoscope more specifically," related Manaker, who is an associate professor of medicine and pharmacology for the Pulmonary and Critical Care Division of the University of Pennsylvania Health System in Philadelphia.

Conventional bronchoscopy has several flaws. When a pulmonologist performs a transbronchial needle aspiration (TBNA), he does the aspiration blindly; "he can't see what's at the end of the  needle," related Manaker. "The physician also can't see a biopsy that's on the outside of the bronchus." For a lymph node biopsy, the pulmonologist has to plunge a needle into the area for biopsy without being able to see it.

Navigational bronchoscopy uses computerized tomography (CT) images and directions from software to target lesion(s), according to the session's handouts. Code +31627 is not imaging specific. You can use the code with any imaging technology, such as radiofrequency, GPS, CT, or MR guidance.

Be careful: Note that +31627, which has 2.0 relative value units (RVUs) or should pay approximately $56.81 using the 2010 Medicare Physician Fee Schedule and conversion factor of $28.4061, is an add-on code. In addition to +31627, you need to separately report either:

• a primary bronchoscopy code (31615, 31622-31631, 31635, 31636, 31638-31643); or

• fiducial marker code (included in the code range above) (31626, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of fiducial markers, single or multiple) (4.16 RVUs or $118.17).

In the planning phase, software creates a virtual 3D CT image. "The pulmonologist then marks the patient's anatomic points and target lesion(s) on the virtual and 3D reconstruction so he can know where he's going when he performs bronchoscopy on the patient," Manaker explained.

Warning: Do not separately report the 3D imaging or fluoroscopic guidance, if used. Code +31627 includes the 3D reconstruction and the fluoroscopy.

In navigational bronchosopy's registration phrase, the pulmonologist uses conventional bronchoscopy, and then inserts a navigation catheter through the channel of the bronchoscope. He uses the navigation catheter to mark live anatomic points that correspond to the previously defined virtual CT image points.

Another new code is for fiducial marker placement (31626). You can report the marker separately from 31627. The fiducial marker(s) can be used to guide a thoracoscopy or to help visualize for a more precise lung wedge biopsy. "Alternatively, the physician can place a marker to designate an area for radiation," Manaker notes.

Beware: Code 31626 is for one or more markers, Manaker stresses. Usually, the physician places four; but a case could require five to six markers. "The code is still reported just once," Manaker said.

To keep 31236 straight from a second 2010-introduced fiducial placement code (32553, Placement of interstitial device [s] for radiation therapy guidance [e.g., fiducial markers, dosimeter], percutaneous, intra-thoracic, single or multiple), answer one simple question. "To tell which of the two codes to use, ask, 'How did the marker get there?' suggested Stephen Hoffman, MD, American Thoracic Society (ATS) AMA CPT Specialty Advisor and Practice Management Committee chair at the 2010 symposium.

Solution: Look at which route the pulmonologist used to place the marker.

• Bronchoscopically: For a fiducial marker bronchoscopically delivered via the airway, report 31626.

• Percutaneously: "If the marker arrived there percutaneously through the chest wall, use 32553," said Hoffman, who is an associate professor of medicine for the Pulmonary and Critical Care Division of Ohio State University and Health System in Columbus.

Code 32553 completes a set of three pleural procedure codes. When a patient has a malignant pleural effusion, instead of inserting a chest tube, the pulmonologist may place a catheter for home fluid drainage, which is described by existing code 32550 (Insertion of indwelling tunneled pleural catheter with cuff).

"Some patients may no longer need the cuffed catheter," Hoffman related. In these cases, a thoracic surgeon or pulmonologist will remove the catheter and report a new code 32552 (Removal of indwelling tunneled pleural catheter with cuff). Code 32553 describes placement of markers for radiation therapy guidance.

When reporting either fiducial placement code, don't forget the device's supply. "Remember to separately report any fiducial HCPCS codes," stated the CPT symposium's "Pulmonary Medicine" handouts. When a physician places markers for navigational bronchoscopy or radiation therapy guidance in the facility or ambulatory surgical center, the facility would bill for the supply. In the office setting, the physician would report the supply, if permitted.

The marker can be made with various items, such as dye, gold, or radiofrequency. Applicable HCPCS codes include:

• A4648 -- Tissue marker, implantable, any type, each

• A4650 -- Implantable radiation dosimeter, each.