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BRONCHOSCOPY AND ASSOCIATED

PROCEDURE CODING IN ICD-10-PCS AND CPT WHY AND HOW IS A BRONCHOSCOPY PERFORMED? Abronchoscopyisatesttoviewtheairwaysanddiagnoselungdisease.Itmayalsobeusedduringthetreatmentofsomelungconditions.Abronchoscopeisadeviceusedtoseetheinsideofthethroat,larynx,trachea,airwaysandlungs.Thescopecanbeflexibleorrigid.Aflexiblescopeisalmostalwaysused.Itisatubelessthan1/2-inchwideandabout2feetlong.Inrarecases,arigidbronchoscopeisused.Thisisdonewhenthereisbleedingintheairwaythatcouldblocktheflexiblescope’sviewsortoremovelargetissuesamplesforbiopsy.Arigidscopemayalsobeusedtoclearfoodorotherobjectsintheairway.

Hereishowthebronchoscopyisperformed:Thescopeispassedthroughthemouthornosethroughthewindpipe(trachea)andintothelungs.Goingthroughthenoseisagoodwaytolookattheupperairways.Goingthroughthemouthallowsthedoctortousealargerbronchoscope.Ifaflexiblebronchoscopeisused,thepatientwillprobablybeawakebutsedated.Duringtheprocedure:• Thepatientwilllikelygetmedicinesthroughavein(intravenously)tohelpthemrelax.Orthepatientmay

beputundergeneralanesthesia,especiallyifarigidscopeisused.• Anumbingdrug(anesthetic)willbesprayedinthemouthandthroat.Ifbronchoscopyisdonethroughthe

nose,numbingjellywillbeplacedinonenostril.• Thescopeisgentlyinserted.Itwilllikelymakethepatientcoughatfirst.Thecoughingwillstopasthe

numbingdrugbeginstowork.• Thedoctormaysendsalinesolutionthroughthetube.Thiswashesthelungsandallowsthedoctorto

collectsamplesoflungcells,fluids,andothermaterialsinsidetheairsacs.Thispartoftheprocedureiscalledalavage.

• Sometimes,tinybrushes,needles,orforcepsmaybepassedthroughthebronchoscopetotakeverysmalltissuesamples(biopsies)fromthebronchialtissuewithinthebronchus.Attimesaforcepsorotherinstrumentsuchasaneedlemaybepassedthroughthebronchialwallintonearbylungtissueproperorlymphnodes.Thisisusuallydoneunderfluoroscopysothephysiciancanseewheretoguidetheinstrument.Thecodershouldreallysearchtheoperativenoteforthisinformationasitmakesadifference.

• Thephysiciancanalsoplaceastentintheairwayorviewthelungswithultrasoundduringtheprocedure.• Sometimesultrasoundisusedtoviewthelymphnodesandtissuesaroundtheairways.Thebelowphotosdepicthowabronchoscopyisperformed:

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ANATOMY OF THE BRONCHUS AND LUNGS AND THE RELATION TO CODING Therespiratorysystemiscomposedofvariousstructures.Itisimportantforthecodertobeabletodifferentiatethesedifferentstructuresasbronchoscopicprocedurescanbeperformedonbronchialtissue,lungtissue,lymphnodes,andotherstructures.Physicianssometimesusetheterm“lung”looselywhentheyactuallyareaddressingbronchialtissue.Theymanytimesuse“lung”and“bronchial”or“bronchus”interchangeably.Thismakesitveryconfusingforthecodertochoosethecorrectcode,especiallyinICD-10-

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PCSbecausetherearebodypartvaluesforbothbronchialtissueandlungtissuebysegment.Thisisafrequenterrorforcoders,codingtolungtissuewhenthephysicianisactuallybiopsyingbronchialtissue.Lookingatthepathologyreportcansometimesbehelpfulhowevermanypathologistsusetheterms“lung”and“bronchial”tissueinterchangeablyaswellintheheaders.Codersmustreadtheentirepathologyreporttoascertainwhattissuewastaken.Itrestswiththecodertoaccuratelyidentifythespecificsiteoftheprocedureortoquerywhenitisnoteasilydiscernablewithinthemedicalrecord.Photo1:Thisfirstphotoisbasic,howeveritdoesshowthattherearethreelobesontherightandtwolobesontheleft.WhencodinginICD-10-PCStherearebodypartvaluesforboththelungandthebronchusineachoftheseareas.

Photo2:Nextwehaveasimplediagramofthesegmentswithinthebronchiandlungs.

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Photo3:ThebelowisanexcerptfromICD-10-PCStoshowthecoderthebodypartvaluesintherespiratorybodysystem.Notethatthereareseparatebodypartvaluesforboththebronchusandlungbylobe.Wehavealsobrokenoutthedifferentbronchopulmonarysegmentsforeachlungfollowingtheexcerpt.

Therightlunghas10bronchopulmonarysegments:

Superior/Upperlobe: Apical

AnteriorPosterior

Middlelobe: Medial

LateralInferior/Lowerlobe: Superior

AnteriorbasalPosteriorbasalMedialbasalLateralbasal

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Theleftlunghas8to10bronchopulmonarysegments:Superior/Upperlobe: Apical(maybecombinedwithposteriortoformapicoposterior)

PosteriorAnteriorSuperiorlingularInferiorlingular

Inferior/Lowerlobe: Superior

Anteriorbasal(maybecombinedwithmedialtoformanteromedialbasal)MedialbasalLateralbasalPosteriorbasal

Photo4:Thephotobelowdepictsthebranchingoutofthebronchusouttothealveoli.Thebronchiolesareconsideredbronchusandthealveoliareconsideredlungtissue.Bronchiolesareminutebranchesintowhichabronchusdivides.Thebronchiolesconnecttothealveoli(airsacs).Alveoliareanyofthemanytinyairsacsinthelungsattheendsofbronchioleswheretheexchangeofoxygenandcarbondioxidetakesplace.Hencetheyareconsideredpartofthelungbodypartvalues.Theyalsohavecapillariesaroundeachalveoluswheretheairexchangetakesplaceintheblood.Whenaphysiciantakeslungtissueafterpuncturingthroughabronchialwall,itisfrequentlyalveoli(lung)tissuewhichisbeingbiopsied.Ahumanadultlungcontainsanaverageof480millionalveoli.

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CODING CHALLENGES IN ICD-10-PCS WewillfirstaddressthenuancesofbronchoscopycodinginICD-10-PCS.DiscussionofCPTcodingwillfollowfurtherbelow.Asmentionedearlier,oneofthemostfrequenterrorscodersmakeiscodinga“transbronchial”biopsytoacodeforlungtissueexcisionwhenthereisnoevidencethatactuallungtissuewasexcised.ThiswillchangetheDRGonthecase.Considerthefollowing:Apatienthasamassoftheleftupperlobe“lung”andisscheduledforbronchoscopicbiopsy.Thephysicianstatesthatthepatientisscheduledfora“lungbiopsy.”Thephysicianinsertsthescope,viewsthebronchialtreeandthentakesanendobronchialbiopsyoftissueintheleftupperlobebronchus.Viewingthepathologyreportvalidatesthisisbronchialtissue.Thebronchusisnotpuncturedandnoactuallungtissueisbiopsied.Pathologyreportconfirmsbronchusmalignancy.INCORRECTCODINGANDDRG: Diagnosis:C34.12,Malignantneoplasmofupperlobe,leftbronchusor lung Procedure:0BBG8ZX,Excisionleftupperlunglobe,endoscopic, diagnostic DRG:168,OtherrespsystemO.R.proc.w/oCC/MCCRW1.3359CORRECTCODINGANDDRG: Diagnosis:C34.12,Malignantneoplasmofupperlobe,leftbronchusor lung Procedure:0BB88ZX,Excisionleftupperlobebronchus,endoscopic, diagnostic DRG:182,Respiratoryneoplasmsw/oCC/MCCRW0.8167Asthecodercansee,assumingthephysician’sterm“lung”literally,canresultinanincorrectprocedurecodeandDRGassignment.ThisisactuallyanareaofOIGandRACreviewerfocus.Keepinmindthattheterm“transbronchial”literallyisdefinedas“through,beyondoracrossthebronchus”howeveritcanalsobeinterpretedas“throughorwithinthebronchus.”Thisiswhyitissuchadifficultcodingarea.ThecoderMUSTreadtheoperativereportandpathologyreporttoascertainwhattypeoftissuewasactuallybiopsied.Theoriginalintentoftheterm“transbronchiallungbiopsy”wastoinferanactualbiopsyoflungtissuewastaken.However,readingmanyoperativereports,coderswillseethatthisisnotalwaysthecase.SincethisimpactstheDRG,attentiontotheactualtissuebiopsiedinthereportisamust.Inaddition,codersmustbecautiouswhenselectingtermsinanencoder.Coderscaneasilybeledtoincorrectcodesdependingonthetermsselected.Codersmustalwaysverifytheircodesinthetabularofbothtypesofcodebooks.

FromtheAHAICD10Codinghandbook:“Bronchoalveolarlavage(BAL),alsocalled“liquidbiopsy,”shouldnotbeconfusedwithwholelunglavage.BALisadiagnosticprocedureperformedviaabronchoscopeunderlocalanesthesia.Itinvolveswashingoutalveolitissueandperipheralairwaystoobtainasmallsamplingoftissue.BALiscodedtotherootoperation“Drainage”becauseitinvolvesremovingfluids.ThebodypartvalueshouldbechosefortheparticularLUNGlobethattheBALisfocusedon.RecentlyAHAupdatedanolderCodingClinic,changingthebodypartvaluetoLUNG:

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CorrectionNotice:BronchoalveolarLavageCodingClinic,FirstQuarter2017:Page51

Summary:CodingClinic,FirstQuarter2016,page26,containedanerrorregardingtheappropriateICD-10-PCScodeforbronchoalveolarlavage(BAL).Thepreviouscodewasassignedtolowerlobebronchusinerror.BALinvolveswashingoutandsamplingalveoliofthelung(smallsacswithinthelungs).TheappropriatecodeassignmentforaBALis0B9J8ZXDrainageofleftlowerlunglobe,vianaturalorartificialopeningendoscopic,diagnosticsincethelungbodypartvaluesmoreaccuratelycapturetheobjectiveofbronchoalveolarlavage,

TheBALoftheperipheralairwaysisincludedinthecodeassignedtothebodypartlungsonoextracodeneedstobeassigned.Sobottomline,forBALassignlungbodypartnotabronchusbodypart.

Wholelunglavageisatherapeuticprocedureperformedforpulmonaryalveolarproteinosis.Theprocedureisperformedundergeneralanesthesiaandmechanicalventilation.Thelungsarelavagedbyfillingandemptyingonelungatatimewithsalinesolution.Thesecondlungisusuallylavagedthreetosevendaysafterthefirstlunghasbeenlavaged.Reportwholelunglavageusingcode3E1F88Z,Irrigationofrespiratorytractusingirrigatingsubstance,vianaturalorartificialopeningendoscopic.Assignalsoacodeforthemechanicalventilationprovided.

Code3E1F88Zwouldnotbeassignedforwashingsonly.SeeCodingClinic,FirstQuarter2017:Page51thataddresseswhenwashingsareperformedwithBAL.

Coderswillneedtoreportseparatecodesforeachseparatelobebiopsied,whetherlungtissueorbronchustissue.Forexample,ifabronchoscopyisperformedandthephysicianperformsendobronchialbiopsyoftherightupperlobebronchusandrightlowerlobebronchus,thentwocodesarereported: 0BB48ZXforthebronchoscopicbiopsyoftherightupperlobebronchus 0BB68ZXforthebronchoscopicbiopsyoftherightlowerlobebronchusIflymphnodeswerebiopsiedviabronchoscopyandTBNA(transbronchialneedleaspiration)thenthebelowcodewouldbeadded:

07B74ZXforthebiopsyofthoraxlymphnodesvianeedle.SeeCodingClinic,FirstQuarter2014p.26.

PROCEDURAL VIDEOS BronchoscopywithEndobronchialBiopsy(5:15)https://www.youtube.com/watch?v=XTC3AKmtrcs(2:21)Inthisvideo,bronchialtissueisobtainedbyforcepsviabronchoscopy.Onlybronchialtissueistakenbytheforceps(orbrushtechniqueifutilized.)Nolungtissueistakenasthereisnopuncturingofthebronchialwall.BronchoscopywithLULbronchialbiopsybyforcepsandBAL(1:05)https://www.youtube.com/watch?v=sxe4SCc6Meg

TransbronchialBiopsyNeedleAspiration(TBNA)ofSubcarinalLymphNodeTissue(7:49)https://www.youtube.com/watch?v=Wcr5LxIZxUkYouwillseeinthisvideothatthephysicianpuncturesthroughthemucosaofthebronchustoguidetheneedleintothesubcarinallymphnode.Thisisactuallyaverycommonprocedure.Manyphysicianschoosetobiopsythethoraciclymphnodestoascertainifamalignant

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tumorhasspreadtothelymphnodes.Thiswillconfirmtheprimaryandsecondarysitesofmalignancy.Thiswouldbecodedto“07B74ZX,Excisionofthoraxlymphatic,percutaneousendoscopicapproach,diagnostic.”

Ifthephysicianwantstoneedlebiopsyalungtumoritself,manytimesthisisdonebyplacingtheneedletransthoracicratherthanthroughthebronchoscope.Seebelow.TransthoracicLungBiopsy:https://www.youtube.com/watch?v=abvYaB2VcmITheneedleisinsertedthroughtheskinandchestwallintothelung,samplestissue,thenwithdrawsneedle.

CODING CLINICS PERTAINING TO BRONCHOSCOPY AND ASSOCIATED PROCEDURES IncludedaretheCodingClinicQ&Asummariesthatareespeciallyimportanttocodersandareinvolvedinerrorsfoundonreviews.PleasebesuretoreadallofthebelowCodingClinicissuesinfullonbronchoscopycodingasthesewillbeutilizedinthequiz.CodersmustreviewanyupcomingCodingClinicsforadditionalinformation.BronchoscopywithSuctioningandWashingsforRemovalofMucusPlugCodingClinic,ThirdQuarter2017:Page14

Summary:SuctionofRULbronchialmucusplugviabronchoscopywithbronchialwashingsiscodedtorootoperationextirpation,0BC58ZZ,Extirpationofmatterfromrightmiddlelobebronchus,vianaturalorartificial

BronchoscopywithSuctioningforRemovalofRetainedSecretionsCodingClinic,ThirdQuarter2017:Page15Summary:SecretionsweresuctionedfromthelowerlobesofthelungbybronchoscopeAssign0B9M8ZZ,Drainageofbilaterallungs,vianaturalorartificialopeningendoscopic,forthesuctioningofthelowerlobesofthelung.CorrectionNotice:BronchoalveolarLavage(BAL)CodingClinic,FirstQuarter2017:Page51Summary:CodingClinic,FirstQuarter2016,page26,containedanerrorregardingtheappropriateICD-10-PCScodeforbronchoalveolarlavage(BAL).Code0B9B8ZX,Drainageofleftlowerlobebronchusvianaturalorartificialopeningendoscopic,shouldbe0B9J8ZX,Drainageofleftlowerlunglobe,vianaturalorartificialopeningendoscopic,diagnostic.BALinvolveswashingoutandsamplingalveoliofthelungandnotthebronchus.

NotethatthebelowinREDFONTisnolongervalid:BronchoalveolarLavage,EndobronchialBiopsyandTransbronchialBiopsyCodingClinic,FirstQuarter2016:Page26

Summary:Abronchoscopyisperformed,bronchoalveolarlavage(BAL),bronchialwashingsandcytologybrushingswereobtainedintherightupperlobebronchus;endobronchialbiopsiesandtransbronchialbiopsiesfromtherightupperlobe;andbronchoalveolarlavagesampleswereobtainedfromtheleftlowerlobe.Thebrushingsarecodedto“excision.”TheBALiscodedto“Drainage”andofthelungbodypart,notthebronchus.Indexstates:

Lavage

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Bronchialalveolar,diagnosticseeDrainage,

RespiratorySystem0B9

FiberopticBronchoscopywithBrushingsandBronchoalveolarLavageCodingClinic,FirstQuarter2016:Page27

Summary:Brushingsviabronchoscopyarecodedtorootoperation“Excision”andbodypartbronchus,usingcorrectlobeandBALiscodedtoDrainage,Lung,andtocorrectlobe.(Correctedvia1Q2017CC)

SelectiveExcisionofParatrachealLymphNodesCodingClinic,ThirdQuarter2014:Page10

Summary:Apatientdiagnosedunderwentflexiblefiberopticbronchoscopy,video-assistedthoracoscopicrightlobectomyandremovaloflymphnodesfromtherightparatrachealstations2,4R,7,9,and10R.Codeto“Excision”oflymphnodesunlesstheMDisqueriedtoseeifachainoflymphnodesareremoved.

CorrectionNotice:TransbronchialNeedleAspirationLymphNodeBiopsyCodingClinic,FirstQuarter2014:Page:26

CodingClinicforICD-10-CM/PCSFourthQuarter2013,pages111-112,wasincorrect.Itshouldnotbedrainagebutbecodedto07B74ZXExcisionofthoraxlymphatic,percutaneousendoscopicapproach,diagnostic.The4Q2013CodingClinichasmoreinformation.

FiducialMarkerPlacementCodingClinic,FirstQuarter2014:Page20

Summary:AradiologicmarkerplacementsuchasafiducialmarkerisnotcodedCodeonlytheinspectionofleftlung,vianaturalorartificialopeningendoscopic.Theappropriaterootoperationfortransbronchialneedleaspirationbiopsyis"Excision."Fineneedleaspirationisdonebyplacinganeedlethroughtissue,applyingsuctionandthetissueisaspiratedforbiopsy.Therootoperationdrainageisusedwhenfluidorgasisremoved,fordiagnosticortherapeuticpurposes(i.e.,collectionoffluidordrainageofabscess).Sotorecap,tissueorcellsiscodedtoexcision,aspirationoffluidonlywithoutcellsiscodedtodrainage.

BrushbiopsyoflungCodingClinic,FourthQuarter1992Page:27to28(NotethatthisisforICD-9-CMhowevertheinformationisclinicalandstillholdstrue)Summary:Thetermbrushbiopsyofthelungisactuallyamisnomer.Thebrushbiopsyisofthebronchus,notthelung.Nolungtissueistakenduringabrushbiopsy.Thisisdifferentfromatransbronchialbiopsywherethebronchoscopebiopsyforcepsactuallypuncturestheterminalbronchusandsamplesoftheperibronchialalveoli(lungtissue)aretaken.

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CPT AND BRONCHOSCOPY CODING MostofthebronchoscopycodesinCPTareinrange31622-31654.Usuallyaseparatecodeisassignedforeachdifferentbronchoscopicprocedure,unlessthereisanNCCIeditthatprecludesthereportingofbothcodes.NCCIeditsshouldbefollowedformostpayorsincludingMedicare.CPTcodingforbronchoscopieshasbeenfairlystraightforward.In2016,theAMAdeletedthecode31620forEBUSduringbronchoscopicdiagnosticortherapeuticinterventions.EBUScombinesabronchoscopewithultrasoundtovisualizethebronchiandadjacentstructures.TheAMAcreatedthreenewcodesforEBUSwithbronchoscopyforthepurposeofobtainingtranstrachealandtransbronchialsamplingoflymphnodesorperipherallesions. Thenewcodesare: 31652withendobronchialultrasound(EBUS)guidedtranstrachealand/ortransbronchialsampling(eg, aspiration[s]/biopsy[ies]),oneortwomediastinaland/orhilarlymphnodestationsorstructures 31653withendobronchialultrasound(EBUS)guidedtranstrachealand/ortransbronchialsampling(eg, aspiration[s]/biopsy[ies]),3ormoremediastinaland/orhilarlymphnodestationsorstructures +31654withtransendoscopicendobronchialultrasound(EBUS)duringbronchoscopicdiagnosticortherapeutic intervention(s)forperipherallesion(s)(Listseparatelyinadditiontocodeforprimaryprocedure[s]) (Use31654inconjunctionwith31622,31623,31624,31625,31626,31628,31629,31640,31643,31645,31646) (ForEBUStoaccessmediastinalorhilarlymphnodestation[s]oradjacentstructure[s],see31652,31653) (Report31652,31653,31654onlyoncepersession)Thebelowphotowillhelptoguidethecoderinwhatlymphnodesareconsideredmediastinal,andwhichlymphnodesareconsideredhilar.Manytimesthephysicianwilldictateinthereportthattheysampledstations4L,4Rand7viaEBUS.Asyouseefromthephotobelow,thesearemediastinallymphnodesandcode31653wouldbeassigned.For31654,thedescriptionintheCPTChanges-AnInsider’sview2016bookgivesaClinicalExampleofthiscodeusedforaperipherallunglesion,whichitdescribesas“outofthevisualfieldofthebronchoscope.”Andtherationaleforthiscodeis:“toidentifytransendoscopicendobronchialproceduresperformedduringdiagnosticortherapeuticbronchoscopicproceduresforlesionsperipheraltothelymphnodestationsorstructures.”Hereisanexampleofacasecodedto31654: 31654Example

Apatientpresentswitha1.5-cmperipherallunglesion.Viatransendoscopicultrasoundprobeguidance,thelesionisidentified.Animagingcatheterisintroducedviathebronchoscope.Thecatheterisdirectedviamultiplesegmentsuntilthedesiredsubsegmentisidentified,toreachandimagethelesiontoconfirmlocationandspecificsofthelesion.Thelesion,whichisoutofthevisiblefieldofthebronchoscope,islocatedanddescribed.Thecatheteristhenremovedandthetargetaccessed.Thecatheterisreintroducedtoreconfirmpositionandaccesstothetarget.Theprocessisrepeatedforeachadditionaltargetlesion.

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CODING CLINIC FOR HCPCS AND CPT ASSISTANTS RELATED TO BRONCHOSCOPY Besuretoreadtheseintheirentirety:UnilateralBronchoscopyCodingClinicforHCPCS,FourthQuarter2015:Page7EndoscopicProceduresCodingClinicforHCPCSSecondQuarter2011Page:1TransbronchialBiopsywithCoreNeedleCodingClinicforHCPCSSecondQuarter2010Page:42011RespiratorySystemSurgery/PulmonaryMedicine/CategoryIIIBronchialValveChangesCPTAssistantJanuary2011,Volume21,Issue1,page6CodingCommunication:BronchoscopyCPTAssistantApril2010,Volume20,Issue9,page5Surgery:RespiratorySystemCPTAssistantMay2008,Volume18,Issue5,pages13-15

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CodingCommunication:BronchoscopyProcedures:ACloserLook

CPTAssistant,August2005,Volume15,Issue8,pages4-6

CodingCommunication:Bronchoscopy

CPTAssistant,September2004,Volume09,Issue14,pages8-10

Manyoldercodingreferenceshaveoutdatedinformationduetocodingchanges

CODING EXAMPLES #1Hereisanexcerptfromanactualoperativereportforabronchoscopywithbronchialbiopsy: “ProcedureDone:Bronchoscopyandbilateralwashings.Washingswithbronchoalveolarlavagefromtherightupperlobe,endobronchialbiopsiesoftherightupperlobewithbrushingfromtherightupperlobe. Procedurenote:Fullsurveyoftheairwayswasachieved…..bilateralwashingsandbronchialalveolarlavagefromtherightupperlobewithendobronchialbiopsiesfromtherightupperlobeandbrushingfromtherightupperlobeallweredonesuccessfullyendoscopically.”ForICD-10-PCSthisprocedureiscoded:

0BB48ZXforexcisionofrightupperlobebronchusviabronchoscopyfordiagnosticpurposes.(ThisincludesboththeendobronchialbiopsiesandbrushingsoftheRUL)"Brushings"arecodedtotherootoperation"Excision"and"lavage"iscodedtotherootoperation"Drainage."

0B9C8ZXfordrainageofRULlungforBALoftherightupperlobeviabronchoscopyfordiagnosticpurposes.SeeCodingClinic,FirstQuarter2017:Page51.Uselungasthebodypart.

Intheindex,washingsisassignedto“irrigation.”Thismaybeconfusingtothecoder.Inourexamplethewashingwasforlavagesothatspecimenscouldbetakenfordiagnosticpurposes,nottoirrigatethebronchusaswesawinthepreviousmessage.Washingisaprocedureinwhichcellsaretakenfromtheinsideofthebronchi.Abronchoscope(athin,tube-likeinstrumentwithalightandalensforviewing)isinsertedthroughthenoseormouthintothelungs.Amildsaltsolutioniswashedoverthesurfaceoftheairwaystocollectcells,whicharethenlookedatunderamicroscope.Bronchialwashingisusedtofindinfections.Itmayalsohelpfindcancerorchangesincellsthatmayleadtocancer.Inourexample,theMDstates“bilateralwashings”yetthereisevidenceofwashingsandlavageofrightupperlobe,notirrigationonly.AndthereisalsoexcisionofRULbronchialtissue.Sincetwodifferentrootoperationshavebeenperformedonthesamebodysite,thenbothcodesarereported.Inaddition,BALiscodedtobodypartLUNGandnotbronchus.Inthiscasethewashingsareactuallypartofthelavageandnotcodedseparately.Codersmustbecarefulwhenthephysicianusestheterms“washing”“irrigation”and“lavage”andlookfortheobjective.ForCPTthisprocedureiscoded: 31623,Bronchoscopy,rigidorflexible,includingfluoroscopicguidance,whenperformed,diagnostic,withcellwashing,whenperformed;withbrushingorprotectedbrushingsforthebrushings 31625,Bronchoscopy,rigidorflexible,includingfluoroscopicguidance,whenperformed,diagnostic,

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withcellwashing,whenperformed;withbronchialorendobronchialbiopsy(s),singleormultiplesites 31624Bronchoscopy,rigidorflexible,includingfluoroscopicguidance,whenperformed,diagnostic,withbronchialalveolarlavage #2Hereisanexcerptfromanactualoperativereportforabronchoscopywithlungbiopsy: “Procedures:1.Flexiblebronchoscopy 2.EBUS,Radialprobe 3.Transbronchiallungbiopsy,RUL 4.BALoftheRUL 5.Fluoroscopy Patientbroughttoprocedureroomandtimeoutperformed.1%lidocainewasusedtoanesthetizetheOP.Moderatesedationwasadministered.Theflexiblebronchoscopewasinsertedviathemouthandintothetrachea.Afullairwaysurveywasperformeddowntothesubsegmentalbronchi.Therewasnoendobronchiallesions.ThescopewaswedgedintheRULwhereaBALwasperformed.ThescopewasadvancedintotheRULandtheradialEBUSprobewasinsertedandusedtoexaminetheperipheralairwaystoidentifythetargetlesion.InthepostRUL,therewere5subsegmentalairwaysseeandwithacombinationofradialEBUSandfluoroscopy,theairwayclosesttothetargetwasidentifiedandtheEBUSprobewasremoved.Underdirectfluoroscopicguidance,transbronchiallungbiopsytimes6wasperformedintheRULofthelocationofthetarget.Moderatebleedingwasnotedandthiswascontrolledusingicesalineand3ccoftopicallyadministereddilutedphenylephrine.Aspirationofbloodysecretionswasperformedandthebronchoscoperemoved. Pathology: LUNG,RIGHTUPPERLOBE,TRANSBRONCHIALBIOPSY: Lightlypigmentedintra-alveolarmacrophages,eosinophilsandneutrophils Negativeformalignancy Nogranulomasidentified Thespecimenisreceivedinformalinlabeledwithpatientnameand“RULTBNA” Fragments3.Sizeslessthan0.1to0.2cm. CassetteSummary:A1threepieces,filteredpleasenotesmallesttissuemaynotsurviveprocessing”ForICD-10-PCSthisprocedureiscoded:

0B9C8ZXforthebronchoalveolarlavage(drainage)oftherightupperlobeviabronchoscopyfordiagnosticbiopsy.SeeCodingClinic,FirstQuarter2017:Page51.Uselungasthebodypart.

0BBC8ZXforthetransbronchiallungtissueexcisionoftherightupperlobeviabronchoscopyfordiagnosticbiopsy.Notethatlungtissueisdocumented.Thisisatruetransbronchiallungbiopsy.

Aspirationofthebloodysecretionsispartoftheoverallprocedure.MostclientsdonotcodetheEBUSinICD-10-PCS.

ForCPTthisprocedureiscoded: 31628,Bronchoscopy,rigidorflexible,includingfluoroscopicguidance,whenperformed,diagnostic,withcellwashing,whenperformed;withtransbronchiallungbiopsy(s),singlelobe.

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31624,Bronchoscopy,rigidorflexible,includingfluoroscopicguidance,whenperformed,diagnostic,withcellwashing,whenperformed;withbronchoalveolarlavage +31654,withtransendoscopicendobronchialultrasound(EBUS)duringbronchoscopicdiagnosticortherapeuticintervention(s)forperipherallesion(s)(Listseparatelyinadditiontocodeforprimaryprocedure(s)](ThisisfortheEBUSidentificationofthelung(peripheral)lesionstobiopsy)

REFERENCES AHACodingClinicICD-10CodingHandbookCPTAssistantWebsitesUtilized:https://www.nlm.nih.gov/medlineplus/ency/article/003857.htmPhotos:http://www.mdguidelines.com/bronchoscopyhttp://web.stanford.edu/group/cfcenter/Bronchoscopy.htmlhttp://medical-dictionary.thefreedictionary.com/bronchoscopyProceednowtotakethe10questionquiz.