Pulmonology Coding Alert

Question: Our pulmonologist evaluated a patient recently for persistent air leak. The patient had previously undergone a bronchial valve placement and after thorough examination, the physician decided to perform a bronchoscopy. The physician’s notes state that she replaced a faulty valve and placed two more valves due to additional leaks in another lobe. How should I code this scenario? In another related case, the pulmonologist performed a diagnostic bronchoscopy and found a massive hemorrhage. In order to protect the healthy right lung from filling up with blood, a bronchial blocker was placed in the left lung. Can I bill for the bronchial blocker placement with valve codes?

Connecticut Subscriber

Answer: A pulmonologist may resort to bronchial placement for treatment of patients with COPD or emphysema or with prolonged air leaks.

If your pulmonologist removed the bronchial valve from one lobe, you will report the procedure using 31648 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve[s], initial lobe). If the pulmonologist removes a valve from a lobe and then inserts another valve in a different lobe, then you should code 31648 for the removal and 31647 (…with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve[s], initial lobe) for the insertion. For example, if your pulmonologist removed one valve from the left lower lobe of the lung and then re-inserted another valve in the upper left lobe, you will report 31648 for the removal and 31647 for the insertion.

As per your info, as your pulmonologist inserted additional valves in other lobes in the same session, you may report additional valve insertions using +31651 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve[s], each additional lobe [List separately in addition to code for primary procedure(s)]) for the insertion in the additional lobe.

You can support the placement with appropriate diagnosis code/s such as J43.0 (Unilateral pulmonary emphysema [MacLeod’s syndrome]), J43.1 (Panlobar emphysema), J43.2 (Centrilobar emphysema), J43.9 (Emphysema, unspecified), or J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection).

Spoiler: Although your pulmonologist might use a bronchial valve insertion in many conditions as mentioned above, many payers often consider this procedure experimental and investigative, and therefore, unpayable. So, it’s a good idea to obtain prior authorization from payers to know if they will provide coverage for the procedure.

For the second case, there is no specific code for this scenario in the CPT® manual. CPT® code 31634 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance [e.g., fibrin glue], if performed) is the nearest for this procedure, but not exactly the same, but in this case the patient did not have an air leak, but rather a hemorrhage. The best bet in such a case would be to use an unlisted code for this service, such as 31899 (Unlisted procedure, trachea, bronchi) and attach detailed documentation of the procedure to the payer.