Pulmonology Coding Alert

Ratchet up reimbursement with these modifiers.

With the heat and humidity expected to hold steady through the summer, respiratory complaints are sure to be on the rise in your office. Now is the ideal time to review Medicare’s Multiple-Endoscopy Payment Rule when coding for bronchoscopies to ensure speedy processing.

Tip 1: Disentangle Fees for Multiple Bronchoscopies

What you need to know: When your pulmonologist performs multiple bronchoscopies, Medicare reimburses 100 percent for the highest-valued procedure. Then, you get paid for each remaining procedure at the allowable rate minus the base rate for a diagnostic bronchoscopy: 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with or without cell washing [separate procedure]).

Payers deduct the base rate from each “surgical” bronchoscopy code reported after the first because the “diagnostic” service is considered part of the “surgical” service, thus the base bronchoscopy value is included in the payment for the highest-valued procedure. And since the base payment is “built in” to all bronchoscopy codes, you can’t expect payment for the initial diagnostic portion more than once. Therefore, you can expect the payer to subtract the dollar amount for the diagnostic portion from the value of the remaining procedures performed that day.  Physicians should never reduce the fees associated with each code.  Submit the codes with the full payment request, and the payer will reimburse accordingly.

Example: If your pulmonologist performs a bronchoscopy on a patient with a localized pneumonia, the procedure might include a BAL (31624), a protected brushing (31623), and a transbronchial lung biopsy (31628), all during the same session.

Since the transbronchial lung biopsy is the most valued service, you should code it first, followed by the less complex codes. You can report all three codes without modifiers since there are no bundling issues with these three codes. Additionally, modifier 51 (Multiple procedures) is an informational modifier that is not required by most payers, and does not affect reimbursement if not used. The payer will pay the physician according to the multiple endoscopy payment rule with or without appending modifier 51.

As far as payment, expect full reimbursement for the highest valued procedure (31628) and reimbursement on the subsequent codes at a lower amount, which equates to the difference between the “surgical” code and the base bronchoscopy code. The formula would look like this: 31628 + [31624-31622] +[31623-31622] = net revenue.

Tip 2: Use the Base Code If the Circumstance Permits

There may be instances when only a diagnostic service is performed.  Let’s look at a scenario which would call for the use of the base diagnostic code 31622.

You be the coder: The patient undergoes a bronchoscopy. If the pulmonologist observes a problem such as a lesion, she may continue the procedure by performing a minor surgical intervention: bronchial biopsy, transbronchial needle aspiration, bronchial brushing, or alveolar lavage.

The pulmonologist would code for the bronchial biopsy (31625) or other procedure codes and not 31622. If the pulmonologist didn’t visualize a lesion, she would finish the bronchoscopy without any intervention and would only bill 31622.

Example: A patient coughs up blood (hemoptysis). The pulmonologist bronchoscopes the patient to find the source of the bleeding and washes the areas where there is bleeding, but is unable to locate a specific bleeding source. The physician finishes the procedure. Report 31622 with 786.3 (Hemoptysis, cough with hemorrhage).

According to Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania, “If the hemoptysis occurs on the same day as the biopsy, and the physician must perform this diagnostic bronchoscopy later that same day, it may be difficult to get reimbursed.  NCCI bundles the diagnostic service into all of the other bronchoscopy codes without the ability to apply a modifier (ie, “Modifier not permitted with code pair”).  You can bill for each, and expect the denial.  You can try to appeal with the procedure reports and the details of the day’s events, but your efforts are not likely to be successful.”

Tip 3: Solve the 51-59 Modifier Conundrum

Achieve optimum reimbursement for multiple bronchoscopies by knowing the scenarios that can put modifiers into play.

As was stated above, reimbursement for bronchoscopies depends on the Multiple Endoscopy Rule. Modifier 51 does not apply to payments for bronchoscopies because the Multiple Procedure Rule (payment for the first procedure is 100 percent, payment for up to four other procedures is 50 percent for each) is not in force. Physician payment for bronchoscopies would be much higher under the Multiple Procedure Rule. Thus, coders can ignore modifier 51 use for bronchoscopy coding.

There are few instances during which a 59 modifier should be used. For example, the National Correct Coding Initiative (CCI) prohibits the reporting of a bronchial biopsy (31625) with either a transbronchial biopsy (31628) or a transbronchial needle aspiration (31629).

The pulmonologist may override this edit by attaching a 59 modifier to 31625, but only when the bronchial biopsy is performed in a site different than the transbronchial lung biopsy or the transbronchial needle aspiration.

Example: A patient undergoes a transbronchial lung biopsy for an infiltrate in the left upper lobe. During the bronchoscopy a lesion is visualized at the right upper lobe takeoff, which is biopsied. The infiltrate in the left upper lobe is biopsied transbronchially with the aid of fluoroscopy. You would code this 31628, 31625-59.

Good catch: If you think that you should consider that the bronchial biopsy and the transbronchial lung biopsy were performed in different areas, you are absolutely right! The bronchial biopsy took place in the right upper lobe and the transbronchial lung biopsy was in the left upper lobe. Because the sites are different for the bronchial and the transbronchial lung biopsies, CCI allows unbundling with the 59 modifier. If the bronchial biopsy had occurred in the left upper lobe bronchus, you would have not been able to bill for it, unless you can demonstrate that they were performed in separate areas of the lobe.