Pulmonology Coding Alert

Reviewed on May 15, 2015

Bronchoscopy is a common procedure. Codes (31622-31656) describe the various methods, often performed in one session. Reimbursement for multiple bronchoscopies can be achieved by knowing what to code separately and which modifiers to use. Use modifier -59 (Distinct procedural service) when separate biopsies are performed on different sites or lesions during the same bronchoscopy. Report modifier -51 (Multiple procedures) to indicate multiple procedures performed at the same setting.

The base code, 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]), is used for the diagnostic portion. The procedure is first performed to examine the inside of the patient’s lungs. If a problem such as a lesion is located, the physician may continue the procedure by performing a surgical intervention: biopsy, needle aspiration, removal or excision, brushing, or alveolar lavage. Because the diagnostic part is inherent to the surgical portion, 31622 is bundled into the other bronchoscopy codes,” says Walter O’Donohue, MD, FCCP, FACP, founder of the CPT® committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT® advisory committee for ACCP. “Pulmonologists can only bill 31622 separately if the bronchoscopy is stopped after looking inside the patient’s lungs or when they only perform bronchial washings.”   

Example: A patient is coughing up blood (hemoptysis). The pulmonologist uses a bronchoscope to find the source of the bleeding and to wash areas where there is bleeding but is unable to locate a problem. The physician stops the procedure. Report 31622 with a diagnosis of 786.3 (Hemoptysis) Under ICD-10, the equivalent diagnosis code will be R04.2, Hemoptysis.

Code Multiple Bronchoscopies Separately with Modifier -59

The main challenge in bronchoscopy coding comes when multiple procedures are performed. Although they may occur during the same session biopsies on different lesions and/or anatomic sites are separate and can be coded as such. When the Correct Coding Initiative (CCI) bundles these procedures appending modifier 59 indicates that two separate biopsies were performed on different sites or lesions during the same bronchoscopy (with the exception of the bronchial biopsy [31625], which can be billed only once). Under the new rule introduced in 2015, you may have to use one of the new X{EPSU} modifiers and modifier 59 will be considered a modifier of last resort. Check payer preferences. “Past CCI edits did not allow a bronchial biopsy (31625) to be coded with a transbronchial biopsy (31628) or a needle aspiration biopsy (31629) even though they are different procedures,” O’Donohue says. The bronchial biopsy is performed with biopsy forceps directed at visible bronchial tissue or a visible endobronchial lesion. The transbronchial lung biopsy is performed peripherally (where the doctor can’t see the lesion directly) by inserting a biopsy catheter into the periphery of the lung usually using fluoroscopic guidance. The needle biopsy is typically performed on central lesions by piercing the bronchus with a needle and sampling a mass or lymph node directly. “Because all these procedures require different techniques and have varied risks CCI changed the rule allowing the procedures to be billed separately with modifier 59,” he says. 

“Medicare certifies six different sites: the right upper lobe, right lower lobe, right middle lobe, left upper lobe, left lower lobe, and the trachea,” says Charlie Strange, MD, FCCP, director of the medical intensive care unit at the Medical University of South Carolina in Charleston. “If a biopsy is performed at different sites on the same patient and the procedures used are bundled you can still bill separately with the modifier 59.” 

Example: A patient presents with extensive right lung pneumonia of all three lobes with an enlarged subcharinal lymph node. The pulmonologist performs a transbronchial lung biopsy in the right lower lobe and a transbronchial needle aspiration of the lymph node. Report 31628 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy[s], single lobe) and 31629-59 (…with transbronchial needle aspiration biopsy[s]), trachea, main stem and/or lobar bronchus[i]). Modifier 59 allows 31628-31629 to be billed separately because the trans-bronchial needle biopsy was performed at a different site and on a different lesion. From 2015, you may be better served by applying the new modifier XS (Separate structure) in place of modifier 59 in this scenario. The modifier is appended to the lesser-valued procedure because it is bundled into the more comprehensive procedure.

When to Use Modifier -51

Sometimes a bronchoscopy includes multiple procedures performed on the same or different parts of the lung. “When different biopsies are performed on different lesions use modifier 59,” O’Donohue says. “However when procedures such as bronchial brushings or alveolar lavage are performed on the same or different lobes with other procedures use modifier 51.”

Example: The pulmonologist performs a bronchoscopy (31622) and sees what appears to be lung cancer in the right upper lobe airways. He performs a bronchial biopsy (31625) of the lesion and a brushing (31623) in the same area. To determine if the cancer has spread to the lymph nodes he performs a transcharinal needle aspiration in the trachea.

The coding for the procedures is 31625 (with biopsy), 31623-51 ( with brushing or protected brushings), and 31629-59. Modifier 51 indicates that multiple procedures (the biopsy and brushing) are performed at the same setting. But the bronchial biopsy and the transbronchial needle aspiration are performed in different areas the biopsy in the right upper lobe and the needle aspiration in the trachea. Because Medicare bundles these two procedures together modifier 59 is attached to the 31629 to indicate the different areas for which separate payment should be made.

Follow the Multiple-Endoscopy Rules

The bronchoscopy codes fall under Medicare’s Multiple-Endoscopy Payment Rule. When multiple endoscopies such as bronchoscopies are performed Medicare pays 100 percent for the highest-valued procedure. The remaining procedures are paid at the allowable fee minus the base (diagnostic) fee for 31622. The payment for 31622 is included in the payment for the highest-valued procedure. Since this payment is “built in” to the intervention codes you cannot be paid for the diagnostic portion more than once. Therefore you have to subtract this dollar amount from the relative value of the remaining procedures performed that day. 

Example: The pulmonologist performs a bronchial biopsy (31625) and a transbronchial lung biopsy (31628) at a different site with brushings (31623) and alveolar lavage (31624). List the transbronchial biopsy first with modifier 59 because it has the highest relative value followed by the bronchial biopsy code which has the second-highest relative value. The brushings (31623) and alveolar lavage (31624 with bronchial alveolar lavage) are appended with modifier 51.  
 
The claim form would appear as:
 31628-59
 31625
 31623-51
 31624-51.
 
In this case some payers may reimburse codes with modifier -51 at a 50 or 25 percent level. Other insurance companies may only pay you for one procedure the highest-valued procedure regardless of the interventions performed.

Coding Therapeutic Bronchoscopies

“Codes 31630-31656 are therapeutic codes,” Strange says. “A therapeutic bronchoscopy treats the problem instead of just diagnosing it,” he says. “There are different techniques used to perform a therapeutic bronchoscopy including lasers cryotherapy and electrocautery.”

Usually the therapeutic bronchoscopy is performed to open up the airways so a patient can breathe. The end result may be placement of a tracheal stent (31631).

Example: A patient receives a bronchoscopy for suspected lung cancer and his right mainstem bronchus is 90 percent occluded with cancer. The pulmonologist uses electrocautery to enlarge the opening to the right middle lobe to 75 percent and places a flexible stent to hold the stenosis open. Report 31641 (Bronchoscopy [rigid or flexible]; when performed; with destruction of tumor or relief of stenosis by any method other than excision [e.g. laser therapy, cryotherapy]) and 31631 (… with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required]) appending modifier 51 to 31631 because it is performed at the same setting. 
 
Note: Pulmonologists often perform therapeutic aspiration bronchoscopy on patients with mucus plugs.
 
Example: A patient with a collapsed lung is in the intensive care unit. The pulmonologist looks into the lungs and sees a buildup of mucus. Suction is used to remove the mucus plugs. Code this type of bronchoscopy with 31645 (…with therapeutic aspiration of tracheobronchial tree initial [e.g. drainage of lung abscess]). If a second drainage is performed report 31646 (…with therapeutic aspiration of tracheobronchial tree subsequent). CCI prevents these codes from being reported together because they are “mutually exclusive.” However if they are performed at different sessions during the day (e.g. the initial therapeutic aspiration in the morning and the subsequent in evening) code for both by attaching modifier 59 to the subsequent aspiration code: 31645, 31646-59. Not all payers will reimburse separately for these codes.

Do Not Bill Conscious Sedation

Many coders believe they can bill for the intravenous conscious sedation during a bronchoscopy if it is administered by the pulmonologist but that is incorrect. “It is part of the procedure,” O’Donohue says. “An anesthesiologist can bill for it but the pulmonologist or an employee of the pulmonologist cannot.”
 
Some private carriers may reimburse if conscious sedation is performed during the bronchoscopy but check with the payer before trying to bill for it. If it is allowed report the appropriate 9914x code. A qualified healthcare professional (such as a nurse or technician) must assist the pulmonologist in monitoring the patient and his or her role should be documented in the operative report.