Pulmonology Coding Alert

Question: Our pulmonologist recently performed bronchoalveolar lavage on a patient. Is it necessary to document the amount of saline used while reporting the lavage procedure?

Maryland Subscriber

Answer: When your pulmonologist performs a bronchoalveolar lavage, he instills about 30-50 ml of saline through the bronchoscope channel into the airways of the lung which is then removed through suction and aspiration into a specimen trap. The material obtained is then analyzed, generally for bacteria, fungi, including pneumocystis, and even for cytology. You report the procedure with 31624 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage).

It is quite common for many coders to get confused if they have to report the use of saline and the amount of saline that has been used for the procedure. The documentation for the procedure should definitely mention the use of sterile saline and to specifically mention the amount of saline that has been instilled into the airways and aspirated out to be sent out to the laboratory.

Note that the documentation of the amount of saline differentiates a bronchoalveolar lavage from a washing (that cannot be separately reported). Furthermore, documentation of the amount of saline used in bronchoalveolar lavage is essential keeping safety of the patient in view and also for the purpose of medicolegal reasons, if necessary.