Pulmonology Coding Alert

Hint: Check the necessity of prior authorization to avoid payer denials.

Counting the number of lobes your pulmonologist worked on is the first step to accurately applying the new CPT^® 2013 codes for “bronchial thermoplasty,” namely 31660, 31661. These codes replaced the former Category III codes 0276T, and 0277T.

Check Payer Rules for Bronchial Valve Insertions

Bronchial thermoplasty is a non-drug, minimally invasive procedure that your pulmonologist might be performing in a patient (18 years or older) with severe asthma that is not responding to any form of medication. During the procedure, your pulmonologist will introduce a radiofrequency catheter through a standard bronchoscope and apply thermal energy to the smooth muscles of the airway in order to clear the airways. Some of the ICD-9 diagnosis that you might see your pulmonologist using this procedure might include:

• 493.00 (Extrinsic asthma unspecified)
• 493.10 (Intrinsic asthma unspecified)
• 493.20 (Chronic obstructive asthma unspecified)
• 493.90 (Asthma unspecified)

Best practice: Although your pulmonologist might perform bronchial thermoplasty in many conditions as mentioned above, payers often consider this procedure experimental and investigative. “Currently, there are some payers who will pay for bronchial thermoplasty and many more will not. Medicare does cover it,” says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. So it’s a good idea to obtain prior authorization from payers to know if they will provide coverage for the procedure in order to avoid the risk of denial.

Choose Appropriate Code Based on Number of Lobes

When your pulmonologist performs bronchial thermoplasty on a patient, you will need to report the procedure based on then number of lobes your pulmonologist worked on. You have two CPT^® codes to report a bronchial thermoplasty procedure.

If your pulmonologist performed bronchial thermoplasty on only one lobe, you will need to report it with 31660 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe). If your pulmonologist applied radiofrequency to the smooth muscles in more than one lobe, you’ll turn to 31661 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, two or more lobes).

Reminder:  Bronchial thermoplasty can be a lengthy process, and your pulmonologist might perform bronchial thermoplasty on a patient in as many as three different sessions. “Bronchial thermoplasty is usually performed in one lower lobe first (31660),” says Plummer. “In about 4 weeks, the other lower lobe has BT (another 31660).  After a wait of another 4 weeks, then both upper lobes receive BT (31661).  The middle lobe does not receive BT.”You will have to report 31660 if your pulmonologist performed the procedure in only one lobe or use 31661 for subsequent session(s) in which he treats more than one lobe.

Note That 31661 is Not an Add-on Code

When your pulmonologist performs bronchial thermoplasty in two or more lobes, you will need to understand that 31661 is not an add-on code, but is a separate, stand-alone CPT^® procedural code.  What this indicates is “that you need not report the application of thermal energy by your pulmonologist in one lobe with 31660 and then report the application of radiofrequency for each additional lobe with 31661, as is the case with other bronchoscopy codes (e.g., 31628, 31632),” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia. So, if your pulmonologist worked on more than one lobe in one session, you will report 31661 and not 31660 along with 31661.

Caveat: As per Correct Coding Initiative (CCI) Edits, 31660 is a column 2 code for 31661 with the modifier indicator ‘0,’ which means that you cannot report these two procedural codes together for the same session under any circumstances.

Example: Your pulmonologist reviews a 20-year-old male patient suffering from severe asthma that is not responding to the use of any form of medication and lifestyle changes. The patient complains that his wheezing events have increased and is not responding to the medication that he was prescribed. This has affected his studies and he has not attended classes regularly in the past one month or so. He complains that he often wakes up in the night, and his asthma is getting worse by the day.

Your pulmonologist provides him with an Asthma Control Test to check the severity of his asthma. The patient fills out the questionnaire and the score from the test is 8.

Based on the inability to control the asthma with conventional medication and on the basis of the results of the asthma control test, your pulmonologist decides to schedule bronchial thermoplasty. You check with the patient’s insurance provider and obtain prior authorization for the procedure.

Procedure details:Under conscious sedation, your pulmonologist introduces a standard bronchoscope into the left lung and then introduces the radiofrequency catheter using the working channel of the bronchoscope. After expansion of the electrode array, your pulmonologist applies thermal energy to the bronchial walls for a period of 10 seconds. This procedure is repeated after your pulmonologist repositions the bronchoscope and the catheter to cover the entire lower lobe. In subsequent sessions, your pulmonologist performs the procedure in the right lower lobe and then repeated in the left and right upper lobe.

What to report:You will have to report 31660 for the first session and the second session in which your pulmonologist treated the lower left and lower right lobe and 31661 for the subsequent session in which your pulmonologist treated both the upper lobes.