Bolster Your Coding Knowledge for BLVR Procedures
Know when a diagnostic bronchoscopy is bundled. Bronchoscopic lung volume reduction (BLVR) with endobronchial valve placement has become an important treatment option for select patients with severe emphysema who remain symptomatic despite optimal medical management. The procedure offers a minimally invasive alternative to surgical lung volume reduction and has demonstrated improvements in lung function, exercise tolerance, dyspnea, and quality of life in appropriately selected patients. For pulmonology coders, accurate reporting of BLVR procedures requires an understanding of CPT® coding, facility billing considerations, patient-selection criteria, and the documentation elements necessary to support medical necessity. Read on to become familiar with the procedures and understand how to correctly report them. Know What Endobronchial Valves Are Endobronchial valves are one-way implantable devices inserted through a bronchoscope into a targeted lobe of the lung. The valves allow trapped air to exit while preventing air from entering the diseased segment during inspiration, ultimately reducing hyperinflation and improving respiratory mechanics. One example of these valves is the Zephyr® Endobronchial Valve. In 2018, the U.S. Food and Drug Administration (FDA) approved the Zephyr® Endobronchial Valve for treatment of severe emphysema associated with hyperinflation in carefully selected patients. Generally, candidates for the procedure are patients with severe chronic obstructive pulmonary disease (COPD)/emphysema who remain significantly breathless despite optimized medical therapy and pulmonary rehabilitation. Appropriate patient selection is critical to achieving successful outcomes. Code Endobronchial Valve Placement The primary CPT® code used to report bronchoscopic valve insertion is 31647 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe). Code 31647 includes airway assessment, sizing, balloon occlusion testing when performed, and valve insertion into the initial lobe. You should not code these components separately. If valves are inserted into additional lobes during the same operative session, report +31651 (… with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), each additional lobe (List separately in addition to code for primary procedure[s]). Code +31651 is an add-on code and you may only report it in conjunction with 31647. Diagnostic bronchoscopy is generally considered inherent to the valve placement procedure and typically is not separately reportable when performed during the same session. Familiarize Yourself With Follow-Up and Revision Procedure Codes The following codes can be overlooked but are highly relevant to endobronchial valve programs: Use code 31648 when the physician removes valves because of pneumothorax, migration, lack of therapeutic benefit, infection, or revision procedures. Also, these two codes are frequently used months or years after the original BLVR procedure when valve revision becomes necessary. I.D. Which Bronchoscopy Codes Are Commonly Encountered During Px Evaluation Patients undergoing BLVR often require diagnostic bronchoscopy before treatment. Code 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)) covers a diagnostic bronchoscopy and is generally bundled into 31647 if the pulmonologist performed both procedures during the same operative session. However, you may report it for a separate diagnostic encounter. Use 31624 (… with bronchial alveolar lavage) when the provider evaluates infection, inflammation, or other pulmonary pathology. Other codes you may use during a diagnostic workup when alternative diagnoses are being evaluated include 31628 (… with transbronchial lung biopsy(s), single lobe) for transbronchial lung biopsy in a single lobe and +31632 (… with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure)) for each additional lobe biopsy. Evaluate the EBUS Codes Often Used During Emphysema Workup Although not part of valve placement itself, many emphysema patients undergo endobronchial ultrasound (EBUS) evaluation. EBUS is a minimally invasive medical procedure that combines a lighted camera scope with sound waves to look deep inside the lungs and nearby lymph nodes. Doctors use it to diagnose lung cancer, infections, and swollen lymph glands without cutting the skin. The CPT® codes for EBUS include the following: The physician may perform these procedures when CT imaging identifies suspicious adenopathy requiring evaluation prior to treatment. Understand the Facility Billing Considerations Most BLVR procedures are performed in the hospital setting because patients require postprocedure monitoring for complications, particularly pneumothorax. Pneumothorax is a known risk following successful lobar collapse and remains one of the most common complications associated with endobronchial valve therapy. Many facilities maintain dedicated BLVR pathways that include preprocedure CT analysis, collateral ventilation testing, pulmonary rehabilitation, and observation or inpatient monitoring after valve deployment. Identify the ICD-10-CM Codes Diagnosis code assignment depends on physician documentation regarding the type of emphysema. Common ICD-10-CM codes include the following: Diagnosis code selection must always reflect the physician-documented condition and associated manifestations. Coding professionals should avoid assigning a specific emphysema subtype unless it is explicitly documented. Dive Into the Documentation Requirements The pulmonologist must clearly document the medical necessity for BLVR in the medical record. Documentation should include the disease severity, patient qualification, procedural documentation, and patient selection criteria. Severity of disease: Review the documentation to ensure the record contains information related to the condition’s severity, such as: Patient qualification: Documentation often contains several factors like: Procedural documentation: The operative report should clearly identify the following: Patient selection criteria: While specific payer requirements vary, common selection factors include the following: Patients with an active pulmonary infection, significant collateral ventilation, large bullae, or contraindications to bronchoscopy may not be appropriate candidates. Takeaways Endobronchial valve placement represents a rapidly expanding therapeutic option for patients with severe emphysema and hyperinflation. From a coding perspective, accurate reporting hinges on proper CPT® code selection, recognition of add-on coding rules, comprehensive documentation of medical necessity, and careful diagnosis coding. As physician adoption of BLVR continues to increase, coding professionals who understand the clinical and reimbursement nuances of these procedures will be well positioned to support compliant billing and optimal revenue integrity. Sarah Jakubowski, CPC, CPMA, RHIT, Consultant,
Pinnacle Enterprise Risk Consulting Services
