Pulmonology Coding Alert
Post-Transplant Condition
Question: How should I code the following chart note: History: The patient is a 42-year-old male with a history of chronic obstructive pulmonary disease (COPD). The patient underwent a bilateral lung transplant six months before the current procedure due to the COPD diagnosis. He presents with a 10-day history of increased shortness of breath and previously noted airway stenosis post-transplant. Preprocedure diagnosis: Airway stenosis and shortness of breath status post bilateral lung transplant. Procedure: The pulmonologist advanced the bronchoscope past the vocal cords and then passed the scope through both anastomoses and removed thick secretions from the patient's bilateral airways. He next observed that secretions were most abundant in the left upper lobe and left lower lobe. The pulmonologist then completed a bronchial alveolar lavage (BAL) of the lateral subsegmental right lower lobe. He instilled 100 ml of saline into the patient's right lower lobe, and the operator received a return of 35 ml of fluid. The pulmonologist then completed transbronchial biopsies x 13 in the right lower lobe. The patient tolerated the procedure well without any immediate complications. The pulmonologist confirmed that the patient did not show signs of pneumothorax using fluoroscopy. Estimated blood loss: 20 ml. Virginia Subscriber Answer: To explain every detail of the patient's condition during the procedure, you should report status/post lung transplant (V42.6), 519.19 (Stenosis of bronchus or trachea), and 786.05 (Shortness of breath). If the pulmonologist determines that the secretions were a transplant complication, also report 996.84 (Complications of transplanted lung). Do not report 996.84 if the patient's current condition is not related to the transplant. Although the pulmonologist obtained multiple transbronchial biopsies, he took all of the biopsies from the right lower lobe. Therefore, you should report only 31628 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy[s], single lobe) for the lung biopsies obtained during bronchoscopy Do this: List the codes in descending relative value order starting with the highest-valued, which in this case is 31628. If the pulmonologist thinks that the removal of the thick, bilateral secretions constituted a therapeutic bronchoscopic procedure, report 31645 (Bronchoscopy, rigid or flexible; with therapeutic aspiration of tracheobronchial tree, initial). Last, report the BAL with 31624 (... with bronchial alveolar lavage). Bonus: Medicare and most other insurers do not require you to append modifier 51 (Multiple procedures) on 31624 because carriers pay for these services through the multiple-endoscopy payment rules. But you should check private payers' modifier 51 policies to see if the insurer requires the modifier for correct payment.
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