Pulmonology Coding Alert

Question: The February Pulmonology Coding Alert contains a reader question about bronchoscopies (Medicare Billing on page 15). We would like clarification, if possible. Recently my physician did a bronchoscopy with left upper lobe and left lower lobe endobronchial biopsies, left lower lobe transbronchial biopsy, left upper lobe brushing, left upper lobe washing and left lower lobe washing. How would you code these procedures? Would you code 31628 x1, 31625-51 x2, 31623 (with or without modifier) and 31624 (with or without modifier) x2?

Melony Dee
Grants Pass, Ore.

Answer: The correct CPT code for bronchoscopy with left upper lobe and left lower lobe endobronchial biopsies and left lower lobe transbronchial biopsy is 31628 (bronchoscopy, [rigid or flexible]; diagnostic, with or without cell washing; with transbronchial lung biopsy, with or without fluoroscopic guidance). Code 31628 can be billed only one time even though multiple bronchial sites were biopsied.

CPT 2000 states, For endoscopy procedures, code appropriate endoscopy of each anatomic site examined. In this case, a different anatomical site doesnt necessarily indicate opposite sides (of the lungs). In clinical practice, each of the five lobes is considered a different anatomical site. Therefore, although the procedure was performed in the same lung, it was performed at a different anatomical site in the lung.

According to the national Correct Coding Initiative (CCI), code 31625 (bronchoscopy, [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]; with biopsy) is a component code of 31628 and cannot be reported separately because this would be unbundling the 31628 procedure. Because biopsies were reported for different anatomical sites of the lung (left upper lobe and left lower lobe), however, you may bill 31625 with a -59 modifier (distinct procedural service) in addition to the transbronchial lung biopsy (31628).

Your question indicated the performance of left upper lobe washing and left lower lobe washing. If the operative report indicates washings, they cannot be billed separately and are part of the code 31628. As stated in the answer to the February issues question although a separate procedure, washings are part of bronchoscopy code 31622 (bronchoscopy, [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]) and cannot be billed more than once.

Review the operative report to determine if the bronchoscopy with biopsies was performed in the left lung, upper and lower lobes. If so, note that the procedure should not be billed twice just because it was performed on two different anatomic sites. If the bronchoscopy was performed with bronchial alveolar lavage, however, report 31624 with modifier -51 (multiple procedures) as multiple procedures to 31628.

You also indicated the surgeon performed a left upper lobe brushing. The correct CPT code for this procedure is 31623 (bronchoscopy, [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]; with brushing or protected brushings). Because this was a secondary procedure (to the 31628), it would be billed with modifier -51 to indicate multiple procedures.

Editors note: Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a healthcare consulting firm specializing in medical management, coding and reimbursement in Spring Lake, NJ, provided information to answer this question.