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Pulmonology Coding Alert

Reader Question:

Separate Biopsy Sites

Published on Sat Sep 01, 2001

Question: A doctor performed a bronchoscopy with biopsies and brushing in the right-middle lobe and biopsies in the right-lower lobe. He used separate diagnosis codes for the two biopsy sites. Will Medicare pay as separate procedures? How should we code the claim?

Louisiana Subscriber
 
Answer: Multiple bronchoscopy procedures should always be reported separately for Medicare. If the biopsies were performed via different methods, the most appropriate code should be reported for each: 31625 (endobronchial biopsy), 31628 (transbronchial lung biopsy) or 31629 (transbronchial needle aspiration biopsy). If the biopsies were performed via the same method, you should use 31625 and 31623 (bronchoscopy [rigid or flexible]; with brushing or protected brushings).
 
Add modifier -51 (multiple procedures) to each additional procedure to indicate that the same provider performed multiple procedures at the same session. Most biopsy procedures performed by the same method are reportable only once despite the number of biopsies taken.
 
There are two options for reporting your service: 1) Report two biopsy codes, one with modifier -59 (distinct procedural service) to indicate the second biopsy is from a separate site (same biopsy method: 31625, 31625-59-51, 31623-51; or different biopsy methods: 31628, 31625-59-51, 31623-51), identifying each distinct biopsy site by its applicable diagnosis code; 2) report one biopsy code with modifier -22 (unusual procedural services) to indicate this procedure was more difficult or more extensive than the average biopsy procedure.
 
Option 1 may cause a claim denial because the code may be recognized by the carrier only once, or the payer, if not Medicare, may not recognize modifier -59. In this case, you may appeal with a copy of the report. Modifier
-22 (in option 2) is typically used when a procedure has a 30-50 percent increase in effort or time, which is reflected in the report. You must send a copy of the detailed report to explain why you are seeking additional reimbursement. When using modifier -22, you also need to indicate the additional amount of reimbursement that you would like to receive.
 
Payment also varies by insurer. Medicare will pay for these procedures according to the multiple-endoscopy payment guidelines. The highest-valued procedure (31625) is paid at 100 percent of its regular rate. Any subsequent procedure (31623) is reimbursed based on the difference between the Medicare allowable payment for the subsequent procedure(s) and the base endoscopy, 31622. Payment for the base endoscopy is subtracted from the subsequent procedure(s) because this payment is included in reimbursement for the primary procedure, 31625. Most private carriers will not reimburse a single provider for more than one endoscopy procedure on the same date. You may be paid for only the highest-valued procedure.

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