Pulmonology Coding Alert

Question: A patient had massive bleeding in the right upper lobe. After the pulmonologist performed therapeutic aspiration, he lavaged the upper lobe and injected epinephrine to control the bleeding. He billed 31645 for the therapeutic aspiration and 31624 for the lavage. Is there anything else that can be billed for control of the hemorrhage?


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Answer: After your pulmonologist cleared the right upper lobe (31645, Bronchoscopy [rigid or flexible]; with therapeutic aspiration of tracheobronchial tree, initial [e.g., drainage of lung abscess]), if he did a bronchial alveolar lavage (31624, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial alveolar lavage) and not just a washing (31622, ... diagnostic, with or without cell washing [separate procedure]), you can bill 31645 and 31624.
 
Codes 31645 and 31624 are not bundled or mutually exclusive, so there is no need for modifier 59 (Distinct procedural service). Often, the bronchoscopy report does not clearly separate the washing from the lavage.

Do this: Ask the pulmonologist if he did a lavage. This means he wedged the scope in the right upper lobe orifices and applied saline with manual suctioning. He then emptied the retrieved specimen in a container for evaluation.

Alternative: You can distinguish a wash from a lavage by looking at two details:

• CC amount: Usually, the amount of saline a pulmonologist uses in a lavage is about 100 cc -- 20 cc instilled five times using a 20-cc syringe. Washing is the instillation of 5-15 cc of saline followed by suctioning to aspirate a small sample for bacteriology or cytology.

• Specimen: The specimen obtained from the lavage represents mostly alveolar cells. But the washing produces mostly airways secretions. No code exists for the epinephrine application, unless the pulmonologist used laser or cryotherapy.

Tip: You might consider modifier 22 for unusual procedural services, if your physician thinks the amount of time spent on the bleeding control was more than 25 percent over and above the usual treatment. Before you do this, make sure you have iron-clad documentation of the extra work the procedure entailed and be prepared to appeal. Answers to You Be the Coder and Reader Questions reviewed by Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta; Carol Pohlig, BSN, RN, CPC, ASC, senior coding & education specialist, department of medicine, University of Pennsylvania Medical Center.