Pulmonology Coding Alert

Question: A patient presented for a diagnostic video-assisted thoracic surgery (VATS) biopsy of their right lower lung lobe after a preoperative diagnosis of hypoxia and shortness of breath. The physician performed a diagnostic VATS biopsy, and the specimen was sent to pathology. During the same surgical session, the results were returned, and the provider decided to perform a surgical VATS with a lobectomy. The postoperative diagnosis is small cell carcinoma of the right lower lobe.

Can we report both the diagnostic VATS and the surgical VATS separately?

Alaska Subscriber

Answer: You can report only the surgical VATS procedure, which in this case would be 32663 (Thoracoscopy, surgical; with lobectomy (single lobe)). Even though the original procedure was a diagnostic VATS, which is coded to 32608 (Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral), a surgical VATS includes a diagnostic VATS.

According to the American Medical Association’s (AMA’s) CPT^® guidelines, a surgical VATS procedure should be reported if a diagnostic biopsy of the lung is performed, the specimen is sent for pathology consultation, and the surgeon uses the results during the same operative session to “determine the extent of the necessary surgical resection.”

To locate the code, turn to the AMA CPT^® index and look for Thorascopy > Surgical > with Lobectomy. Then you’ll turn to the Respiratory chapter of the CPT^® code set to confirm the code choice.

Next, depending on your individual payer preferences, you can append modifier RT (Right side) to indicate laterality — in this case the right side of the patient’s body or their right lung.

Don’t forget the diagnosis: The pathology report came back with a diagnosis of small cell carcinoma of the right lung, which is coded to C34.31 (Malignant neoplasm of lower lobe, right bronchus or lung). In the ICD-10-CM Alphabetic

Index, Carcinoma directs you to “see also Neoplasm, by site, malignant.” In the Table of Neoplasms, you’ll search for Neoplasm, neoplastic > lung > lower lobe, and then you’ll examine the Malignant Primary column where you’ll find C34.3- (Malignant neoplasm of lower lobe, bronchus or lung). When you verify the code in the tabular list, you’ll notice the code requires a 5th character to complete the code. For this code, the 5th character “1” indicates laterality.