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Question: A pulmonologist in our practice performed a flexible bronchoscopy with endobronchial ultrasound (EBUS) guidance on a 70-year-old patient. The physician is evaluating a persistent right upper lobe (RUL) pulmonary nodule that was identified on a chest CT. The CT also revealed enlargement of the right paratracheal and subcarinal lymph nodes. The pulmonologist performed transbronchial needle aspiration (TBNA) on stations 4R and 7. Pathology results are still pending.

How should we report the EBUS-guided TBNA of multiple mediastinal lymph node stations when the pathology isn’t available?

Washington Subscriber

Answer: Assign 31652 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures) to report the EBUS-guided bronchoscopy with TBNA. The pulmonologist performed the TBNA on two stations, 4R and 7, which fall under 31652’s descriptor.

Double-check the documentation to make sure it includes EBUS guidance, each lymph node station that was sampled, the medical necessity for the procedure, and the needle aspiration technique.

Next, you’ll turn to the ICD-10-CM code set to assign the correct diagnosis codes for the encounter. Since the pathology results have not returned yet, you’ll need to identify the signs or symptoms that show the medical necessity for the procedure. A prior CT scan showed a RUL pulmonary nodule, so you’ll assign R91.1 (Solitary pulmonary nodule) to report the nodule. You’ll also use R59.0 (Localized enlarged lymph nodes) to report the enlarged lymph nodes that were found on the CT scan.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC