Pulmonology Coding Alert

Question: Is it necessary for my pulmonologist to document saline usage, or the amount of saline used, in order for me to report 31624?


Oklahoma Subscriber

Answer: Remember that 31624 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial alveolar lavage) always involves saline use. Coders often wonder whether the amount used and whether the physician dictates the saline use in his report affects how they report the procedure.

The physician's report must mention sterile saline use, but the pulmonologist doesn't have to identify the amount of saline instilled and aspirated for the purpose of physician billing and reimbursement. But the physician should document the saline amounts for patient safety and medicolegal purposes.

When a pulmonologist performs a bronchoalveolar lavage, he wedges the bronchoscope into an area and administers saline in 20-ml aliquots into that area. The patient must then aspirate the saline into a sterile syringe or trap after each aliquot, and the pulmonologist then stores the saline in one or more containers for analysis.