vmounce
Guru
I am not completely understanding the rules of coding bronchoscopies. Could someone familarize it for me. If bronchial brushings and endobronchial biopsies are done in same area, is it okay to code both 31623 and 31625 together? If so, would I use same diagnosis for both codes? I appreciate any information. Please see op report below:
PROCEDURE: Fiberoptic bronchoscopy.
INDICATIONS: Left hilar mass with enlarged pulmonary lymph nodes with strongly positive PET scan highly suspicious of bronchiogenic carcinoma. Bronchoscopy is performed to obtain a histological diagnosis.
ANESTHESIA: General and topical anesthesia with lidocaine 2% and 1% respectively.
OPERATIVE PROCEDURE: After obtaining consent from the patient and explaining to her the risks of the procedure including bleeding and infection, the patient was brought to the endoscopy suite. A time-out was called and the patient's name and date of birth were confirmed as well as the site of the tumor confirmed on the chest CT report. Topical anesthesia was achieved by instilling Hurricaine spray and viscous Lidocaine in the nares and oropharynx respectively. Conscious sedation was achieved by the anesthesiologist by using IV Diprivan. The bronchoscope was introduced through the right naris and advanced. The vocal cords were visualized and appeared normal. The vocal cords were anesthetized with 2% Lidocaine. The bronchoscope was advanced down the trachea which was normal with a sharp carina. The trachea and carina were anesthetized with 2% Lidocaine and the lower area was anesthetized with 2% Lidocaine respectively.
The bronchoscope was briefly introduced into the right mainstem bronchus and the subsegments of the right upper, middle, and medial segment of the right lower lobes were briefly examined and were normal.
The bronchoscope was then advanced down the left mainstem bronchus and the subsegments of the left lower lobe were examined and appeared normal.
The bronchoscope was introduced in the left upper lobe and the lingua was normal. The anterior segment was normal. There was some heaped-up mucosa in the posterior segment of the left upper lobe. The apical segment was normal. Bronchial brushings followed by several endobronchial biopsies were obtained from this abnormal area. Following the biopsies, the washings were again repeated.
Throughout the procedure pulse, blood pressure, and O2 sats were monitored and remained relatively stable. Except for coughing and some bleeding, the patient tolerated the procedure fairly well and there were no major complications. The washings, brushings, and biopsies were all sent for cytology and histopathology.
IMPRESSION: Abnormal mucosa in the posterior segment of the left upper lobe suspicious for a tumor.
PROCEDURE: Fiberoptic bronchoscopy.
INDICATIONS: Left hilar mass with enlarged pulmonary lymph nodes with strongly positive PET scan highly suspicious of bronchiogenic carcinoma. Bronchoscopy is performed to obtain a histological diagnosis.
ANESTHESIA: General and topical anesthesia with lidocaine 2% and 1% respectively.
OPERATIVE PROCEDURE: After obtaining consent from the patient and explaining to her the risks of the procedure including bleeding and infection, the patient was brought to the endoscopy suite. A time-out was called and the patient's name and date of birth were confirmed as well as the site of the tumor confirmed on the chest CT report. Topical anesthesia was achieved by instilling Hurricaine spray and viscous Lidocaine in the nares and oropharynx respectively. Conscious sedation was achieved by the anesthesiologist by using IV Diprivan. The bronchoscope was introduced through the right naris and advanced. The vocal cords were visualized and appeared normal. The vocal cords were anesthetized with 2% Lidocaine. The bronchoscope was advanced down the trachea which was normal with a sharp carina. The trachea and carina were anesthetized with 2% Lidocaine and the lower area was anesthetized with 2% Lidocaine respectively.
The bronchoscope was briefly introduced into the right mainstem bronchus and the subsegments of the right upper, middle, and medial segment of the right lower lobes were briefly examined and were normal.
The bronchoscope was then advanced down the left mainstem bronchus and the subsegments of the left lower lobe were examined and appeared normal.
The bronchoscope was introduced in the left upper lobe and the lingua was normal. The anterior segment was normal. There was some heaped-up mucosa in the posterior segment of the left upper lobe. The apical segment was normal. Bronchial brushings followed by several endobronchial biopsies were obtained from this abnormal area. Following the biopsies, the washings were again repeated.
Throughout the procedure pulse, blood pressure, and O2 sats were monitored and remained relatively stable. Except for coughing and some bleeding, the patient tolerated the procedure fairly well and there were no major complications. The washings, brushings, and biopsies were all sent for cytology and histopathology.
IMPRESSION: Abnormal mucosa in the posterior segment of the left upper lobe suspicious for a tumor.