Pulmonology Coding Alert

Question: A pulmonologist performed electrocautery resection of endobronchial tumor, had an hour of critical care (cc), and bronchoscopy and wash. What codes should I report that describe these procedures?

Massachusetts Subscriber

Answer: You may use 31641 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction...) to represent the tumor resection since it describes tumor destruction by any method other than excision. Meanwhile, the bronchoscopy and wash may represent cell washings or a bronchial alveolar lavage (BAL) -- depending on the extent of the "washing." The September 2004 CPT Assistant describes BAL as involving repeated instillations of sterile saline occurring in aliquots with aspiration into one or more containers. The procedure involves a physician putting large amounts of saline (20- 30 ccs per instillation) into the airway and suctioning the secretions into a container which he then sends to the microbiology and pathology laboratories for analysis.

Careful: This is not the same as routine washings (no large aliquots of saline), which are not separately reportable. It may be that the "washings" are merely routine washings and, therefore, are included in 31641. A safe way to go is to look to the physician's documentation to distinguish between these "washing" services. If the "washings" can be documented as a BAL, you should bill 31624 (...with bronchial alveolar lavage) in addition to 31641.

Heads up: In order for the physician to report one hour of critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes), documentation must clearly identify that the procedure time was not included in the amount of critical care time reported. You may not count the time for any separately billable procedures into the physicians critical care time. You should  remember that the payer will want to see that these two encounters occurred independently of one another.