Pulmonology Coding Alert

Question: A patient was referred to our practice for a biopsy of a lesion. The physician performed a transbronchial needle aspiration (TBNA) biopsy and a transbronchial forceps biopsy on the same peripheral lesion on the same single lobe to capture sufficient samples for testing.

Do I need to report multiple procedure codes for the visit?

West Virginia Subscriber

Answer: Yes, you will assign multiple CPT^® codes for the visit since the physician performed two separate procedures. For the transbronchial forceps biopsy, you’ll assign 31628 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe). You’ll then assign 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)) for the TBNA biopsy.

Some coding experts debate whether 31629 is specific to central airways, but the descriptor doesn’t indicate this. Therefore, you may correctly report 31629 for a peripheral lesion biopsy.

Back it up: The provider’s documentation should back up the medical necessity for both procedures, as performing two different types of lung biopsies on the same lesion may be considered unusual. If the clinical documentation stated the physician performed the needle aspiration first, but the results of the sample were inconclusive, then the forceps biopsy is medically appropriate and should be reported separately.