Pulmonology Coding Alert
Reporting Multiple Units of 31625 For Multiple Biopsies/ Sites? Watch Out
Question: Our pulmonologist recently performed a bronchoscopy on a patient. During the procedure, he found two lesions in the right and left lobes. He performed biopsies of both the lesions and sent them to the lab for analysis. I want to report 31625 for the procedure that our pulmonologist performed. But, my question is since he performed the biopsies in two different areas, should I report two units of 31625? Should I use RT and LT modifiers to my claim? Please let me know.
Answer: When reporting any bronchoscopic procedures (31622-31656), you cannot use the modifiers RT (Right side [used to identify procedures performed on the right side of the body]) and LT (Left side [used to identify procedures performed on the left side of the body]) as the 150 percent bilateral payment adjustments are not applicable to these set of codes.
You are right in choosing 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy[s], single or multiple sites) to report the procedure that your pulmonologist performed. If you look at the descriptor to 31625, it covers a single endobronchial biopsy or multiple endobronchial biopsies in one site or in many sites. So, regardless of the number of biopsies and the number of sites that your pulmonologist performed the procedure, you will have to report only one unit of 31625 per session.
However, if your pulmonologist performed a transbronchial needle aspiration biopsy in one site and endobronchial biopsy in the other site, then you can report the procedures separately as two different procedures were employed. Here you will report 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy[s], trachea, main stem and/or lobar bronchus[i]) to report the aspiration biopsy and 31625 with the modifier 59 (Distinct procedural service) for the other biopsy. Documentation should be specific to reference the exact methods used for each biopsy site.
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