Pulmonology Coding Alert

Question: How do we properly code with modifiers for the following procedures on a Medicare patient?

1. Bronchoscopy with fluoroscopy
2. Washing x 1
3. Brushing x 1
4. Biopsy x 7

Lonnie Lolio
Pulmonary Disease & Critical Care Associates
Columbia, Md.

Answer: Effective Jan. 1, 2000, the Health Care Financing Administration (HCFA) is including fluoroscopy with bronchoscopy (31622-31646). Fluoroscopy will no longer be reimbursed as a separate procedure. Last April, bronchoscopy codes were changed to multiple endoscopic procedure codes. If you bill bronchoscopy (31622), youre billing for fluoroscopy whether or not you perform the fluoroscopy.

Although its unlikely you will perform a washing, you cannot bill for multiple washings. CPT defines a bronchoscopy as 31622 (rigid or flexible; diagnostic, with or without cell washing [separate procedure]). Although a separate procedure, washings are a part of bronchoscopy code 31622 and cannot be billed more than once. A brushing is coded 31623 (bronchoscopy, with brushing or protected brushings). This code is considered a progressive code, which means it also includes the washing (31622). The most expensive reimbursable progressive code should be billed first, followed by its previous code. Medicare should pay the full value of the most expensive code, as well as the difference between that code and the one before it.

In other words, each progressive code pays the difference between the base code, 31622, and the procedure before it.

Suppose you bill a 31624 (bronchial alveolar lavage), and a 31623 (bronchoscopy with brushing or protected brushings). Since the bronchoscopy codes are multiple endoscopy codes, the full value of 31625 (with biopsy) should be paid as well as the difference between the 31622 and 31623, which is the second code.

As with the previous washing and brushing codes, multiple biopsies can only be billed once, no matter how many biopsies are performed. If youre billing private pay carriers, it is possible you could bill a 31623 with a -51 modifier (multiple procedures), which represents a second procedure done at the same setting. This billing procedure actually reimburses at a rate 50 percent higher than the other codes.

Editors note: Advice for these reader questions was provided by Walter J. ODonohue, MD, FCCP, Creighton chair, CPT/RUC committee of the American College of Chest Physicians, representative to the AMA CPT advisory committee for the American College of Chest Physicians, Chief, Pulmonary/Critical Care, University Medical Center, Pulmonary & CCM Division, in Omaha, Neb.