Pulmonology Coding Alert

Question: Our pulmonologist is insisting that we bill 31622 two times for a patient on whom the two procedures were done in the same day. I am not able to understand how we can do this, as 31622 has a Medically Unlikely Edit (MUE) number of 1, which means that we can bill the procedure only once in a day.

Nevada Subscriber

Answer: You are right in your assessment that 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) carries a Medically Unlikely Edit number 1; that means you cannot bill the procedure more than once in a day under most circumstances.

However, CMS provides guidelines for bypassing MUE edits that state that you can append an appropriate modifier to the same CPT® code on more than one line of the claim form. So by appending the appropriate modifier, when medically necessary, you can override the MUE edit and claim appropriate reimbursements for the procedure that has been done.

In the above described scenario, since the procedure involves the repeat of the same procedure requiring the patient's return to the operating room for the procedure, you can append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure to 31622.

If the first procedure was previously terminated for unforeseen reasons, you can append modifier 53 (Discontinued procedure). Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure.

Note: Modifier 53 is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite).

Ensure that you are maintaining and providing adequate documentation to the payer to justify that the second procedure was essential so that you will not risk the chance of denials to your claims.