Pulmonology Coding Alert

Revised NCCI edits bring hope for bronchoscopy denials.

Get ready for good news if you face denials for using endobronchial ultrasound (EBUS) codes. According to an update by the American Thoracic Society (ATS), the NCCI edits have been revised, and you might be able to appeal a denial from the past. Read on to know more.

Background: This year, the old code for EBUS was replaced by the following new codes:

• 31652 – Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures)
• 31653 –… 3 or more mediastinal and/or hilar lymph node stations or structures
• +31654 – Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s]). 

Codes 31652 and 31653 represent complete services, including sampling (aspiration/biopsy of lymph nodes or nearby structures), using endobronchial ultrasound. You report the codes separately, according to the number of lymph node stations explored. CPT^® code 31654 is an “add-on” code that is used when peripheral lesions (distal to the hilar structures) identified by radial EBUS are sampled.

Keep these facts in mind for EBUS:

• Diagnostic code 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) is included in the new codes.
• Codes 31652 and 31653 include the work of sampling such as transbronchial needle aspiration codes such as 31628, 31629, 31632, and 31633.
• However, if additional bronchoscopy is performed distal to the hilar structures, you may need to use additional bronchoscopy codes along with the EBUS codes.
• Code +31654 may be used with any other bronchoscopy codes when a peripheral lesion is sampled.

Blame Your EBU Denials on the January CCI Edits

According to the ATS update, there were errors in the NCCI edits for 31652 and 31653 published on Jan. 1, 2016, in that the value for all other bronchoscopy codes was “0.” In addition, CCI 22.0 also restricted you from billing the EBUS with:

• 32440-32445 — Removal of lung, pneumonectomy…
• 32480-32491 — Removal of lung, other than pneumonectomy…
• 32501 — Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure)
• 32503-32504 — Resection of apical lung tumor (e.g., Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed…
• 32505-32506 — Thoracotomy….

Consequently, the payers started rejecting any claims for 31652 or 31653 whenever any a provider reported any other bronchoscopy code on the same claim. After receiving the feedback from various stakeholders and associations, CMS corrected the edits to include bronchoscopy procedures as reimbursable when performed in addition to EBUS, with a convex probe sampling proximal lesions. Even then, these corrections took time to get implemented, and took effect in April 2016.

The impact differs: The impact of this issue seems to have varied from place to place. “We do bill for EBUS, but we have not yet heard from our billing company that they can’t get paid on the EBUS or that we are seeing a lot of denials,” says Lisa Center, CPC, Physician Practice Manager at Via Christi Hospital Pittsburg, Inc., in Pittsburg, Ks.

Nevertheless, the fact remains that NCCI edits needed to be revised. “CMS suggested that claims be held, or resubmitted after the correction became effective,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “ATS tried to notify their membership of this issue so that the claims were not just written off by the billing staff.”

Act fast: You will need to ask your staff to have a look at your denied claims. “Having someone review the claims denials involving these codes will be necessary in order to properly process the denials,” feels Pohlig. In case you did get denials involving this case scenario, try to talk to your payers – you could be on your way to a successful resubmission of the claim.