Pulmonology Coding Alert

Hint: Obtain prior authorization to avoid payer denials.

To correctly report the new CPT^® 2013 codes for “bronchial valve insertion and removal,” namely 31647, 31648, +31649 and +31651, focus on the number of lobes and the number of valves that were inserted or removed to understand when to apply these codes. These codes replaced the former Category III codes 0250T, 0251T, 0252T.

Check Payer Rules for Bronchial Valve Insertions

Endobronchial valves are used in patients to control air leak and as an alternative for surgical interventions such as lung volume reduction surgery; these valves may be used for conditions such as emphysema, chronic obstructive pulmonary disease (COPD), and pneumothorax. Your pulmonologist might also insert an endobronchial valve to control a prolonged air leak or in conditions such as significant air leak, which if left uncorrected, might turn into a prolonged air leak.

Best practice: Although your pulmonologist might use a bronchial valve insertion in many conditions as mentioned above, payers often consider this procedure experimental and investigative. So it’s a good idea to obtain prior authorization from payers to know if they will provide coverage for the procedure.

Count Lobes for Appropriate Bronchial Valve Reporting

When reporting bronchial valve insertion or removal, you will have to check the number of lobes in which the valves were inserted or removed to arrive at the right code.

If your pulmonologist is inserting bronchial valves in one lobe, you report 31647 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve[s], initial lobe), irrespective of the number of valves he inserted in that lobe. “Code 31647 is to be used for the insertion of one or more valves in a single lobe” says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

If your pulmonologist inserted an endobronchial valve(s) in one lobe and then inserted additional valve(s) in another lobe, you will have to report 31647 for the initial insertion and the add-on code, +31651 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), each additional lobe [List separately in addition to code for primary procedure(s)]) for the insertion in the additional lobe.

Tip: You will report only one unit of +31651 regardless of the number of valves he inserted in the additional lobe. Report additional units of +31651 only if the documentation shows your pulmonologist inserted the valves in more additional lobes.

Example: Your pulmonologist reviews a patient for persistent air leak. The patient had previously undergone a surgical resection. When the patient’s air leak did not subside even after placing a chest tube, your pulmonologist decides to perform the placement of bronchial valves to stop the air leak.

Your pulmonologist introduced a flexible bronchoscope that he advanced to the site of the air leak using fluoroscopic guidance. He then advanced a sizing balloon in the affected airway to assess the air leak and to check the size of the valve that would be needed to stop the air leak.

Once the air leak was assessed, your pulmonologist selected the appropriate size valve and deployed it through the deployment catheter to the area where the air leak was present. The procedure was repeated in another lobe where another air leak was present. The positioning of the valves was then confirmed.

What to code: You will report 31647 for the insertion of the first valve and +31651 for the second bronchial valve placement.

Report Bronchial Valve Removals on Same Guidelines as Insertions

If your pulmonologist removed the bronchial valve from one lobe, you will report the procedure using 31648 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve[s], initial lobe).

If your pulmonologist removed the valves from more than one lobe, you will have to report one unit of 31648 for the removal from the initial lobe and one unit of +31649 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve[s], each additional lobe [List separately in addition to code for primary procedure]) for removal of the valve(s) from each additional lobe.

Use These Guidelines for Same Session Removal and Insertion

When your pulmonologist removes a previously placed bronchial valve, and then in the same session inserts another valve, you will have to report the removal and the insertion separately.

“If the pulmonologist removes a valve from a lobe and then inserts another valve in a different lobe, then you should code 31648 for the removal and 31647 for the insertion,” says Plummer. For example, if your pulmonologist removes one valve from the left lower lobe of the lung and then re-inserts another valve in the upper left lobe, you will have to report 31648 for the removal and 31647 for the insertion.

If in the same session, if your pulmonologist inserts additional valves in other lobes, you have to report additional valve insertions using +31651. In the same manner, valve removals from additional lobes will have to be reported using +31649.