Pulmonology Coding Alert

Scan the note for bronchus or lung location to assign 5^th digits for malignant neoplasms.

How often does your pulmonologist identify a suspicious nodule on a patient’s lung or airway? The answer’s got to be “frequently.” Selecting the right codes to describe the nodule’s location and status as a benign or malignant growth can help ensure an accurate claim — and deserved payment.

Know Your Nodules

A pulmonary nodule, also called a “spot on the lung” or a “coin lesion,” is a small round (usually less than 3 cm) lung growth that can be malignant or benign. A nodule usually develops as a result of a lung infection, a non-infectious cause such as rheumatoid arthritis, or from a neoplasm that can be cancerous, according to the Cleveland Clinic’s patient information site.

Silent but possibly deadly: Typically, a patient with nodules isn’t aware of them; if there are symptoms, those would be related to the condition that caused the nodule, such as in the case of lung cancer, when the patient may have a new cough or cough up blood, the Cleveland Clinic indicates. 

Dx testing: Initial imaging from CT scans and chest X-rays can determine the size and whether growth is emergent, says the Clinic. If the physician suspects the latter, a PET scan can be done to determine metabolic activity that may merit a biopsy, which can be done via bronchoscopy or needle biopsy through the chest wall, particularly when the nodule is located near the edge of the lung near the wall, the Clinic site says.

Turn to Abnormal Findings Dx

If the diagnostic imaging (CT, MRI, or PET scan) shows what the physician determines is an abnormal pulmonary nodule, you’ll report a code from R91 (Abnormal findings on diagnostic imaging of lung). For example, choose R91.1 (Solitary pulmonary nodule) when the results show a single nodule.

Pinpoint the Neoplasm Site

When, following a biopsy procedure, the pathology results identify that the nodule is a malignant neoplasm, you’ll report one of the following codes from the C34 (Malignant neoplasm of bronchus and lung) range, initially basing your code search on the location of the malignant nodule as indicated by the 4th digit:

• C34.0- (Malignant neoplasm of main bronchus)
• C34.1- (… upper lobe, bronchus or lung)
• C34.2 (… middle lobe, bronchus or lung)
• C34.3- (… lower lobe, bronchus or lung)
• C34.8- (… overlapping sites of bronchus and lung)
• C34.9- (… unspecified part of bronchus or lung)

Next step: For all of the above codes except C34.2, you’ll need to delve deeper to determine an appropriate 5th digit to further specify the nodule location in the main bronchus or upper, middle, or lower lobe. For instance, if the malignant nodule biopsied was in the patient’s right bronchus, lower lobe, you’d report C34.31 (Malignant neoplasm of lower lobe, right bronchus or lung). For a malignant neoplasm in the patient’s right main bronchus, you’d choose C34.01 (Malignant neoplasm of right main bronchus).

If the neoplasm is in an unspecified part of the right lung, you’ll report C34.91 (Malignant neoplasm of unspecified part of right bronchus or lung).

Check Out These Nodule Biopsy Scenarios

Coding scenario 1: A 68-year-old established male patient has been recently discharged from the hospital for pneumonia and your physician performs a single-view chest x-ray as a follow-up to evaluate whether the infection is fully resolved. The x-ray shows a single pulmonary nodule of 4 cm in the middle lobe of the right lung that was previously noted but has not resolved, which your physician decides to biopsy to assess for possible malignancy. The bronchoscopy biopsy confirms that the nodule is benign.

For the procedures report:

• 71045 (Radiologic examination, chest; single view) for the chest x-ray
• 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)) for the biopsy
• Attach R91.1 (Solitary pulmonary nodule) as the diagnosis to indicate the abnormal single nodule.

Coding scenario 2: Your physician sees a 75-year-old female patient who’s a former smoker with a persistent cough. A single view chest x-ray reveals a pulmonary nodule 5 cm in size and irregularly shaped on the upper lobe on the right lung, which your physician biopsies using bronchoscopy with needle aspiration. The nodule biopsy reveals a malignant neoplasm.

You’ll report:

• 71045 (Radiologic examination, chest; single view) for the chest x-ray with R91.1 (Solitary pulmonary nodule) attached to indicate the abnormal single nodule identified in the x-ray.
• 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)) for the biopsy with diagnosis code C34.11 (Malignant neoplasm of upper lobe, right bronchus or lung).