Pulmonology Coding Alert

Diagnostic scopes do not always translate to 32601. Find out why.

Whether it's internally inspecting the pleura, lungs, and mediastinum, or obtaining tissue for testing purposes, thoracoscopy involves several operative procedures that can sometimes be misleading without coding guidelines to follow.

Examine the following statements, and familiarize yourself with various truths and fictions surrounding thoracoscopy.

1. You Can Report Diagnostic Scopes Separately

Truth. CMS' Correct Coding Initiative (CCI) specifically states that if the surgeon performs a diagnostic thoracoscopy on the same day as the open thoracotomy procedure, you may report the endoscopy separately. This means any diagnostic thoracoscopy (32601-32606) performed by a surgeon that determines the need for an open surgical procedure should be reported separately.

Example: The surgeon examines a patient with pain and breathing difficulty (32601, Thoracoscopy, diagnostic [separate procedure]; lungs and pleural space, without biopsy) using diagnostic thoracoscopy. As a result of the test, the surgeon identifies and locates a foreign body in the pleural space, and removes the object via thoracotomy (32150, Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit). This case calls for reporting both 32601 and 32150.

Caution: Not all "surveys" done via a diagnostic scope should warrant a 32601 code. If the surgeon uses a diagnostic scope to "scout" the surgical field -- to establish anatomic landmarks or to discern the extent of disease -- you cannot report the diagnostic scope separately, says M. Trayser Dunaway, MD, a surgeon, speaker, coding educator and healthcare consultant in Camden, S.C. The diagnostic scope must lead directly to the decision to perform surgery.

2. You Cannot Bill Multiple Surgical Thoracoscopies

Fiction. You can report as many surgical scopes as you want, provided they are truly warranted, and performed at different sites during the same operative session.

Example: The surgeon uses the thoracoscope to induce adhesion (32650, Thoracoscopy, surgical; with pleurodesis) for a patient with repeated pneumothorax. At the same time, he performs a segmentectomy (32663, ... with lobectomy, total or segmental). You should bill 32663 on the claim, followed by 32650.

Case-to-case: The payer may impose a multiple-procedure payment reduction on the second (and any subsequent) scope as these rules do apply to these surgical services. In other words, the payer reimburses at 100 percent for the first or primary procedure and 50 percent for the second procedure. Payers are unlikely to reimburse related each service at their full rate since each of these procedures build upon one another.

3. You Cannot Unbundle Diagnostic and Surgical Scopes

Truth. In case a diagnostic thoracoscopy precedes a surgical thoracoscopy (32650-32665), you would report only the surgical thoracoscopy -- regardless of whether the results of the diagnostic scope prompted the need for the "intervetional" scope. "Surgical thoracoscopy always includes diagnostic thoracoscopy," says Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C., basing her statement from CPT instructions.

Other Key Points To Remember

Example: Consider the case in which the surgeon attempts to remove a foreign body in the pleural cavity. Initially, she attempts to use the thoracoscope (32653), but encounters difficulties. She then decides to abandon the scope and remove the foreign body via thoracotomy (32150). You would report only the open procedure (32150).

The above example tells you that you should report only the successful procedure when the surgeon must convert an endoscopic procedure (such as a thoracoscopy) into an open procedure (such as a thoracotomy).

Strictly a no-no: Never report 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]) in addition to thoracoscopy procedures 32601-32665 since 32422 is already an integral component of thoracoscopy. Why? The surgeon creates a pneumothorax (32422) to provide pleural space between the lung and chest wall, or else he cannot move the instruments around easily and cannot visualize all areas of the thoracic cavity.