Pulmonology Coding Alert

Question: A pulmonologist performed a bronchoscopy under fluoroscopic guidance. Prior to suctioning, he positioned a Wang needle toward the subcarinal mass, which resulted in minimal aspiration. He continued with the bronchoscopy and found a bulging mass in the right lower lobe. He performed several washings, brushings and biopsies at this location. Should I report 31629 and 31623?

Nebraska Subscriber

Answer: Yes. The pulmonologist’s use of the needle for aspiration indicates a transbronchial needle aspiration, which you should code with 31629 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial needle aspiration biopsy[s], trachea, main stem and/or lobar bronchus[i]). For the brushings, assign 31623 (… with brushing or protected brushings).

Don’t overlook: Choose the correct biopsy code based on the type. For an endobronchial biopsy, meaning one that the pulmonologist took under direct visualization of the lesion, use 31625 (… with bronchial or endobronchial biopsy[s], single or multiple sites).

For a transbronchial biopsy, one that the pulmonologist obtained from the lung’s periphery using fluoroscopic guidance or blindly, assign 31628 (… with transbronchial lung biopsy[s], single lobe).

Biopsy code 31625 includes multiple biopsies at one or several sites within the airways. Code 31628 includes multiple biopsies within one lobe. If the physician obtains transbronchial lung biopsies from more than one lobe, use add-on code +31632 (… with transbronchial lung biopsy[s], each additional lobe [list separately in addition to code for primary procedure]) for each additional lobe sampled. So report 31625 with one unit, regardless of how many biopsies the pulmonologist performed, but code each lobe from which the pulmonologist obtains transbronchial lung biopsies using 31628 for the first lobe and 31632 for subsequent lobes.

If the service involved both bronchial or endobronchial biopsy(s) and transbronchial biopsy(s), CPT allows you to report both 31625 and 31628. The Correct Coding Initiative, however, does not permit coding this combination (31625 and 31628) unless the biopsies occur on different sites of the lung or different lesions.

To alert the Medicare carrier to the “special circumstances” that allow payment for both procedures, you must append modifier 59 (Distinct procedural service) to the procedure that, under normal circumstances, is not separately reportable -- the standard biopsy code (31625-59).

You should not append modifier 51 (Multiple procedures) to the brushings and biopsy(s) code unless the payer instructs otherwise. CPT and Medicare require no modifiers when coding bronchoscopy procedures, except for modifier 59 for the combination of 31625 and 31628 mentioned above, and modifier 59 for the combination of 31625 and 31629 for the same reason.

Medicare calculates the payment for multiple bronchoscopic procedures by paying for the most complex procedure in full and by paying for the difference between the next procedure(s) and the base bronchoscopy code (31622). List the procedures in descending order. For instance, the claim may contain:

• 31629 (5.60 transitional facility total relative value units)

• 31628 (5.24 RVUs) or 31625 (4.71 RVUs) (31625-59 if added to 31628 or 31629)

• 31623 (4.03 RVUs).

The facility payment for 31622 is 3.98 RVUs. In this example, if the pulmonologist performed a transbronchial needle aspiration (31629), a bronchial biopsy (31625) and a bronchial brush (31623), he would receive payment for 5.60 RVUs for 31629, 0.73 RVUs for 31625 and 0.05 RVUs for 31623 for a total of 6.38 RVUs (about $241.79) using the 2007 Medicare Physician Fee Schedule and a conversion factor of 37.8975.

Answers to You Be the Coder and Reader Questions answered/reviewed by Cindy C. Parman, CPC, CPC-H, RCC, president of Coding Strategies Inc. in Atlanta; Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta; and Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.