Pulmonology Coding Alert

31622 is often bundled into other bronchoscopy codes

When coding diagnostic bronchoscopies, you'll have to decide when to report the base bronchoscopy code and when to leave it off the claim.
  
And if you cannot recognize scenarios in which the pulmonologist performs bronchoscopy with bronchial alveolar lavage (BAL), a denial could head your way. Check out this expert advice on reporting your diagnostic bronchoscopies.

Use 31622 for Diagnostic Procedures

When the physician inserts a bronchoscope and visualizes the vocal cords, tracheobronchial tree, major lobar and segmental bronchi for abnormalities, this typically represents a diagnostic bronchoscopy. Code these encounters with 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]), says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

Coders should use 31622 as the "base" bronchoscopy code, says Jill Young, CPC-EDS, president of Young Medical Consulting LLC in East Lansing, Mich. Often, the physician performs the diagnostic bronchoscopy as a first attempt to diagnose or manage the presenting problem, and this may determine the need for additional intervention.

Example: A patient reports coughing up blood. The pulmonologist performs a diagnostic bronchoscopy with washing to try to find the source of the bleeding. In this instance, you should report 31622 for the service. Don't forget to link ICD-9 code 786.3 (Hemoptysis) to 31622 to prove medical necessity for the procedure.

The pulmonologist may schedule a diagnostic bronchoscopy after running other tests to check the patient's lung status. These other tests might be a chest x-ray, a computed tomography (CT) scan, or a pulmonary function test (PFT).

Example: A patient reports he has had a cough for three months. After performing spirometry with graphic record and a CT of the chest on day one, which do not pinpoint the patient's problem, the pulmonologist performs a diagnostic bronchoscopy on day two to assess the cause for the cough.

For the day-one claim, report the following:

• 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) for the spirometry

• 786.2 (Cough) linked to 94060 to represent the patient's cough.

Note: You may need to append modifier 26 (Professional component) to 94060 if the service occurs in a hospital-based office or pulmonary function laboratory. 

For the day-two claim, report:

• 31622 for the bronchoscopy.

•  786.2 (Cough) linked to 31622 to represent the patient's cough.

Mucous Plugs Often Prompt Bronchoscopy

Patients with chronic obstructive pulmonary disease (COPD) or bronchiectasis may require diagnostic bronchoscopies so the physician can locate and treat mucous plugging, Berman says.

Example: An established patient with bronchiectasis reports complaining that he cannot breathe easily. A chest x-ray reveals an atelectasis of the right middle lobe. The pulmonologist performs a diagnostic bronchoscopy, finds that the atelectasis is secondary to a large mucous plug and aspirates it.

On the claim, report the following:

• 31645 for the service

• 518.0 (Atelectasis), 786.09 (Dyspnea), and 494.x (Bronchiectasis) to represent the patient's final diagnosis (atelectasis), presenting symptoms (breathing difficulty), and underlying condition (bronchiectasis).

Observe 31622 Bundle on Biopsy Bronchoscopy 

There are also instances in which your pulmonologist performs a diagnostic bronchoscopy and another bronchoscopy procedure, such as a biopsy, during the same session. When this occurs, you should leave 31622 off the claim and just code for the other bronchoscopy, Berman says.

Why? The Correct Coding Initiative (CCI) bundles 31622 into all other bronchoscopy codes (31623-31656). 

For example, a patient with a chronic cough reports to the practice. A chest x-ray demonstrates infiltrates in the right upper and left lower lobes. The pulmonologist performs a diagnostic bronchoscopy, then takes multiple transbronchial lung biopsies from the two lobes.

When the physician decides to take biopsies, it is no longer a diagnostic procedure, and you should leave 31622 off the claim. In the above example, report the following:

• 31628 (... with transbronchial lung biopsy[s], single lobe) for all biopsies taken in the first lobe.

• +31632 (... with transbronchial lung biopsy[s], each additional lobe [list separately in addition to code for primary procedure]) for all biopsies taken in the
second lobe.

• 786.2 (Cough) and 793.1 (Abnormal chest x-ray) attached to 31628 and 31632 to prove medical necessity for the procedures.

Alveolar Sampling Indicates BAL Bronchoscopy

If the notes indicate that the pulmonologist performs a bronchoscopy with BAL, choose 31624 (... with bronchial alveolar lavage) instead of 31622.

The difference: A BAL is more involved than a diagnostic bronchoscopy. During a BAL, the pulmonologist wedges the bronchoscope into a specific bronchus. The pulmonologist then installs a large amount (100-120 mL) of sterile saline in aliquots of 20-30 mL through the bronchoscope into the lungs. Fluid is then suctioned out into one or more containers. The pulmonologist verifies the specimen volume and sends it to the lab for specialized testing including cultures, cytology and cell counts. 

Pulmonologists perform BAL bronchoscopies to diagnose unusual infections, pneumonia in ventilator patients, and cancer. The procedure also helps to guide therapy in chronic inflammatory or fibrotic disorders, such as idiopathic pulmonary fibrosis.

Study This Example

A patient reports with a chronic cough and abnormal sputum. A chest x-ray shows a bilateral interstitial pattern. 

The pulmonologist performs bronchoscopy and wedges the bronchoscope into the right middle lobe. A total of 120 mL of saline is instilled into the lobe through the bronchoscope. The physician then suctions the saline out of the bronchi through the bronchoscope and sends the specimen off to the lab after recording the volume instilled and the volume removed from the right middle lobe.

In this instance, the physician performed a BAL. On the claim, report 31624 for the service. Remember to include 786.2, 516.9 (Unspecified alveolar and parietoalveolar pneumonopathy) and 786.4 (Abnormal sputum) on the claim to represent the patient's symptoms.

Payers May Vary on BAL Specifics

There is some controversy as to what exactly constitutes a BAL bronchoscopy, Young says. For this reason, you'll want to proceed carefully when considering the 31624 code.

According to the Ingenix 2007 Coder's Desk Reference of Procedures, 31624 is appropriate when "a bronchial alveolar lavage allows lung tissue to be sampled by irrigating with saline followed by suctioning the fluid."

But check out CPT's more detailed description of a 31624 service, as it appears in the CPT Reference of Clinical Examples:  

"The physician inserts the bronchoscope through the upper airway, noting any abnormalities.  The vocal cords are visualized, and the structure and function are noted.  The bronchoscope is advanced into the tracheobronchial tree. The bronchoscope is wedged into the area under study, and saline is inserted through the bronchoscope into the area and then aspirated into a sterile syringe or trap. The saline is instilled in 20-mL aliquots. After each aliquot is infused, it is aspirated into one or more containers. Usually, the total volume infused by site is 100 mL to 150 mL."

Best bet: Make sure the physician's actions (and the documentation) reflect the more extensive work associated with CPT's 31624 definition. Otherwise, report 31622 for a diagnostic bronchoscopy with (simple) washing.