Pulmonology Coding Alert

Hint: Don’t forget to check for any  separately reported guidance.

When your pulmonologist places fiducial markers, you’ll need to concentrate on the method of insertion and guidance used rather than worrying about the number of markers placed. Review the advice that follows to navigate your way to the right codes.

Check Indications Marker Placement

Fiducial markers are markers that your clinician will use as a reference point to help in other therapeutic procedures or in radiation therapy. Some of the situations wherein your practitioner will employ the use of these markers will include:

• As a reference point for planning of radiation therapy and to accurately deliver the radiation to the specific site.
• As a guide during thoracoscopy
• For improved visualization during lung wedge biopsy to attain better degree of precision.

Use Method of Insertion as Guide to Appropriate Reporting

When your clinician places fiducial markers, you’ll have to report the procedure based on how your pulmonologist reached the point to place the marker. “Your clinician will employ two methods of insertion, namely, endoscopic and percutaneous,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia. “Depending on the approach, you’ll have to report the fiducial marker placement appropriately.”

If your pulmonologist places the markers endoscopically by performing a bronchoscopy, you’ll report the procedure using 31626 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of fiducial markers, single or multiple).

Alternatively, if your clinician used a percutaneous method of insertion of the markers, you’ll resort to reporting the procedure with 32553 (Placement of interstitial device[s] for radiation therapy guidance [e.g., fiducial markers, dosimeter], percutaneous, intra-thoracic, single or multiple).

Example: Your pulmonologist reviews a 65-year-old female patient to place fiducial markers to help treat a tumor by stereotactic radiosurgery using Cyberknife. As the patient has high risk of developing pneumothorax if the markers are placed percutaneously, your pulmonologist decides to place the markers through bronchoscopy. You’ll report the marker placement using 31626 as the markers were inserted endoscopically.

Capture Marker Placement Only Once

If you look at the descriptors to placement of the fiducial markers, you’ll observe that the same descriptor covers single or multiple marker placement. “Irrespective of the method employed to place the markers, endoscopic or percutaneous, you’ll report the appropriate CPT^® code for the marker placement only once,” adds Pohlig.

For instance, in the above mentioned example, if your pulmonologist inserted four fiducial markers bronchoscopically to act as reference points for the delivery of radiation using Cyberknife, you’ll report the marker placement using only one unit of 31626 and not report four units of 31626.

Know When to Report Guidance Used for the Procedure

If your pulmonologist is using fluoroscopic guidance to place the markers through bronchoscopy, you should not report the guidance used for the procedure separately as this is included in the descriptor of 31626.

However, for a percutaneous placement, you’ll have to report the imaging guidance (depending on the type of guidance used) separately with one of the following codes:

• 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation)
• 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device])
• 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation)
• 77021 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation)

New way: A much newer method that your pulmonologist might use is electromagnetic navigation bronchoscopy (ENB). This procedure differs from conventional bronchoscopy in that with ENB, your pulmonologist will use a 3D reconstruction using the patient’s chest CT to navigate precisely to the area where the markers are to be placed.

If your pulmonologist uses ENB guidance to place the markers bronchoscopically, you’ll have to report the ENB procedure separately along with 31626. The ENB will have to be reported using the add-on 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)]).

Caveat: Some payers consider the use of ENB with flexible bronchoscopy for the assessment of pulmonary lesions or for the placement of fiducial markers as investigational and might deny reimbursement for this add-on code. So, prior to reporting ENB with +31627, check with the payer to see if the procedure is covered to avoid the risk of denial.