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Whether the physician adds fluoroscopy, stents or other services to the bronchoscopy procedure, coding professionals should know what you can report separately and what’s included in the global package.

By Jill M. Young, CPC-EDS
When reading the CPT® codebooks’s respiratory section, coding pulmonary procedures seems like it should be relatively straightforward. The section includes a limited number of codes, and not many new codes have been introduced in the past 10 years. So, why is there so much confusion over how to bill within the endoscopy sections for trachea and bronchi codes? Let’s look at what the CPT® codebook offers us as guidance in answering some frequently asked questions about coding bronchoscopic procedures.
A bronchoscopy is a procedure to aid in the evaluation and treatment of lung patients. Most often, the physician uses a fiberoptic scope and performs the procedure in the endoscopy suite of the hospital. Other locations include an office setting or perhaps at the patient’s hospital bedside. Completed for a variety of reasons, only 21 CPT® codes describe these services. Physician documentation is the key to proper code selection.
A diagnostic bronchoscopy is inherently bilateral. Most patients have two lungs and the pulmonologist would evaluate both during this procedure. This answers the first of the frequently asked questions on how to bill when the physician examines both bronchi. The code should be reported only once because “looking” down both of the mainstem bronchi is innately part of the procedure. The anatomy of the lungs is such that the physician travels down the trachea toward the opening branches to each of the lungs via the bronchial openings, and looks into both of these airways in his or her inspection of the lungs.

Know the Diagnostic and Surgical Codes

Several types of diagnostic procedures can be done through the bronchoscope. Viewing abnormalities and evaluating other conditions such as a chronic cough, bleeding or even a collapsed lung are possible. During bronchoscopies, physicians may also acquire specimens of an abnormality (e.g., infection, tumor) that are then analyzed by a pathologist. Biopsies, brushings or bronchial alveolar lavages (BALs) are included in the 31623-31633 range of codes. Therapeutic procedures include use of the scope to remove foreign bodies such as inhaled pieces of food. Newer technology allows the bronchoscope to be used for laser treatment, insertion of stents and perhaps for therapeutic aspiration of a lung abscess. These procedures are included in the 31630-31646 code range.
Another frequently asked question concerns billing for fluoroscopic guidance that may be needed during the bronchoscopic procedure. CPT® tells us, “codes 31622-31646 include fluoroscopic guidance when performed.” This notation includes all but one of the codes in this endoscopy section, so practices should not bill separately for guidance, according to CPT®. The code for diagnostic bronchoscopy is 31622. Guidelines at the beginning of this CPT® section qualify that a diagnostic bronchoscopy is always included with any of the other surgical bronchoscopy codes when completed by the same physician. CCI bears this out in its billing restrictions on any combination of codes from the section. Some coding professionals are not aware of this exclusionary edit when asking whether they can bill 31622 in conjunction with other bronchoscopy codes.
This answers yet another question of billing for bronchoscopy codes. The guidelines at the beginning of this endoscopy section indicate that you should “code appropriate endoscopy for each anatomic site examined.” Most pulmonologists consider this notation to indicate a lobe location such as right upper lobe or right lower lobe. As always, physician documentation of this differential is key in how you can code services. Without specific documentation, codes for an additional site should not be considered. Notations after some codes such as 31628, 31629 and 31632 (transbronchial biopsies) state that the code should be reported only once, regardless of how many biopsies are taken on the lobe or upper airway location. But what about the other codes?
The September 2004 CPT Assistant noted that 31625 “should be reported only once, even if performed at different anatomical sites.” Other codes in this section were not considered in the article. Otherwise, the “each anatomic site examined” notation should be considered in your code selection. As always, payers may have differing payment policies on this code set. Questions regarding the billing of multiple codes within the section are frequent, and coding professionals must look at the documentation, CPT® instructions and the individual payer to achieve an answer. A few add-on codes in the section indicate either an additional lobe that was biopsied or additional bronchus stented. These codes are reported in addition to the code for the primary procedure. The procedure report must clearly indicate that the “additional” lobe or bronchus was affected in order to use these add-on codes.

Consider 31620 for EBUS

The 2007 CPT® codebook lists 31620 (EBUS) as “Endobronchial ultrasound during bronchoscopic diagnostic or therapeutic intervention(s).” This procedure, which involves a special bronchoscope that has an ultrasound at its tip, is the newest technology for biopsying mediastinal nodes. EBUS allows the physician better visualization of the structures and provides a different level of guidance for bronchoscopic procedures. This equipment allows the physician to perform a minimally invasive procedure in lieu of a mediasteinoscopy (an open surgical procedure) that has more risks involved for the patient.
Code 31620 is an add-on code that is listed in addition to the primary procedure code. When looking at the CPT® codebook for this endoscopy section of the respiratory system, there are a plethora of notations that should aid you in your code selection. As is always the case, documentation is the first and most important part of your journey. Correct billing of bronchoscopies should be straightforward, and with the above questions answered, should be easier than ever.
Jill Young, CPC, is president of Young Medical Consulting LLC in East Lansing, MI. Young conducts educational seminars nationally as a member of the speakers’ panel for the AAPC, and locally for the Michigan State Medical Society. 

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