Pulmonology Coding Alert

CPT®:

Simplify Your EBUS Billing Claims by Highlighting Lymph Node Stations

Published on Wed Sep 08, 2021

Knowing the number of lymph node stations examined determines your code selection.

Billing endobronchial ultrasounds (EBUS) can be tricky, but if you have the proper documentation and research to back up your claims, then it will be easier for your pulmonology practice to receive payment.

“Research is what’s going to save you in trying to work with your payers. Give them the good information they need to consider these [codes] procedures and not call them experimental,” says Jill Young, CEMA, CPC, CEDC, CIMC of Young Medical Consulting LLC in East Lansing, Michigan in a webinar on bronchoscopy billing.

Read on to learn how to properly bill for an EBUS.

Diagnose Different Lung Conditions with an Endobronchial Ultrasound

Scenario: A 67-year-old patient is referred to your pulmonology practice after an X-ray showed an abnormality in the right lung. The pulmonologist performs an EBUS to help diagnose the mass. During the procedure, the physician feeds the flexible tube through the patient’s mouth, windpipe, and into the right superior lobar bronchus where they’re able to use the ultrasound to capture images of the mass and lymph nodes, as well as collect a sample from the mass. The pulmonologist lists 11R, 10R, and 12R nodal stations in the documentation. Following the outpatient procedure, the pathology report comes back as non-small cell lung cancer (C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung).

Physicians perform an endobronchial ultrasound to help diagnose different lung symptoms, which include infections, inflammation, and cancer. The EBUS features a flexible tube that’s equipped with an ultrasound probe, video camera, lights, and even a small needle for tissue sample collection. A physician performs the procedure to collect tissue or fluid samples for laboratory analysis, or diagnostic or therapeutic interventions.

Check Out Lymph Node Stations

So, how do you properly code an EBUS for billing purposes? You’ll find numerous CPT^® codes for bronchoscopies, but CPT^® only designates three codes for endobronchial ultrasounds. When the physician performs the procedure to obtain tissue or fluid samples for analysis, you’ll choose between 31652 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/ biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures) and 31653 (…, 3 or more mediastinal and/or hilar lymph node stations or structures).

“In order to report the correct number of stations sampled during EBUS, a coder would have to know the locations and corresponding lymph node stations,” says Carol Pohlig, BSN, RN, CPC and Manager, Coding & Education in the Department of Medicine at the Hospital of the University of Pennsylvania in Philadelphia. If the pulmonologist performs the procedure on only one or two stations or structures, then you’ll use 31652. When the EBUS is performed on three or more structures or stations, you’ll code the procedure with 31653. These two CPT^® codes are ideal for procedures involving localized nodes and tumors, diagnosing and determining the staging of tumors, and examining lesions between the lungs.

Station explanation: The descriptors for 31652 and 31653 call out “one or two” and “three or more…stations or structures,” respectively. The stations refer to the lymph nodes throughout the mediastinal region and are categorized based on their location, such as upper and lower paratracheal, subaortic, subcarinal, hilar, interlobar, lobar, and more. Pohlig adds, “Only certain stations are accessible through an EBUS technique. Physicians can assist with identifying the structures sampled and labeling a diagram of the sampled locations.”

Most categories carry an R or L in addition to the number to signify if the station is on the right or left side of the body. In the previously mentioned scenario, the R is attached to each station number, so you can confidently report the EBUS was performed on the patient’s right side.

If the pulmonologist performs an EBUS for a diagnostic or therapeutic intervention of peripheral lesions, you’ll use +31654 (…; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s])).

Code +31654 is an add-on code that will be used in conjunction with the following codes and code families:

31622-31626 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; …)
31628 (…; with transbronchial lung biopsy(s), single lobe)
31629 (…; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i))
31640 (…; with excision of tumor)
31643 (…; with placement of catheter(s) for intracavitary radioelement application)
31645 (…; with therapeutic aspiration of tracheobronchial tree, initial)
31646 (…; with therapeutic aspiration of tracheobronchial tree, subsequent, same hospital stay)

For +31654, you’ll list the code separately in addition to the appropriate code that matches the primary procedure performed. For example, if the pulmonologist performed the EBUS following the removal of a tumor, you would code the procedures as 31640 with +31654. This indicates the pulmonologist initially performed the tumor excision and followed with the EBUS procedure for diagnostic purposes.

Documenting the Procedures Will Back Up Your Claims

Your EBUS billing claim still has a possibility of being rejected. “EBUS, when it was a standalone code, was frequently rejected as experimental. It is now more widely paid for, so don’t be afraid to go back to your carriers with good literature and ask them to reconsider and make payment for [the procedure(s)],” Young says. Additionally, some payers may consider an EBUS investigational and won’t cover the procedure. The key is to ensure you have the dictation and the documentation to back up the medical necessity for an EBUS.

To help alleviate headaches when billing for EBUS and other bronchoscopies, the pulmonologist should document all codes pertaining to the procedures they performed. This will allow you to determine which codes to bill, as some codes may be bundled together, and help ensure your pulmonology practice is receiving accurate reimbursement.

Additionally, you can report 31652, 31653, and +31654 only once per session. This means that regardless of how many stations or structures the pulmonologist examines during the EBUS, you can only report one of the codes once per visit.