Topic 1.4: Coding Resource: Bronchoscopy
CPT Code and Procedure Description
Description
Diagnostic/Therapeutic
Indications
31620,
endobronchial
ultrasound
(EBUS)
A flexible bronchoscope with
a biopsy channel is inserted.
Then a miniaturized
ultrasound catheter probe
bearing a mechanical
transducer at its tip that
rotates 360 degrees is
inserted. The catheter has a
balloon at the tip that, after
being filled with water,
provides complete circular
contact. The probe is moved
along the axis of the airways,
attempting to localize and
examine the ultrasound
characteristics of the lesion.
An ultrasound picture is
taken for the patient’s record
even if the lesion is not
identified.
Enhancing visualization (eg,
differentiating vascular from
non-vascular structures),
providing guidance (eg,
transbronchial needle
guidance), assisting in
assessments (eg, tumor
volume) and in other
interventions (eg, airway
recanalization).
31622,
bronchoscopy,
diagnostic,
flexible
Flexible bronchoscopy:
The bronchosope tip is
introduced transnasally or
transorally with the use of a
bite block. Lidocaine solution
is then injected through the
bronchoscopic channel in
2ml aliquots for anesthetizing
the vocal cords and entire
tracheobronchial tree.
31622,
bronchoscopy,
diagnostic,
rigid
Rigid bronchoscopy: This
procedure is performed
under general anesthesia
with a side arm or high
frequency jet ventilator. The
neck is hyperextended, and
the scope is introduced into
the trachea.
Specimen
Assessing malignant disease, Bronchial
early diagnosis of carcinoma, washings.
assessing operability,
transbronchial or
endobronchial lung biopsy,
minor hemoptysis, persistent
chronic cough, removing
foreign bodies (minor role),
diagnosing lung infections
(especially in
immunocompromised hosts),
and difficult endotracheal
Once adequate anesthesia
has been attained, a detailed intubation.
visual examination is
performed. Subsequently,
other procedures such as
biopsies, washings and
brushings can be carried out.
Removing foreign bodies,
Bronchial
controlling massive
washings.
hemoptysis, and
endobronchial laser
photoresection or debulking of
endobronchial tumors.
Bleeding sites can be
visualized, foreign bodies
may be removed, and
biopsies of suspicious lesions
may be obtained. A large
array of instruments can be
used with the rigid scope.
31622,
bronchoscopy
with washing continued
Code 31622 describes
bronchoscopic evaluation if
the tracheronchial tree with
sterile saline washings of the
bronchus obtained and sent
for culture and/or cytologic
examination.
Bronchial washings: The
bronchoscope is passed in
the usual manner. Isotonic
saline is instilled through the
inner channel of the
bronchoscope. Fluid is
aspirated into a trapconnected inline to the
suction tubing.
Cytological cell typing for
tumors.
Bronchial
secretions,
washings.
* Brushings or protected
brushings take significantly
more time to perform than
bronchoscopy with cell
washing. See code 31623 to
report brushing and protected
brushings.
For endoscopically visible
lesions, the fluid is washed
directly over the area in
question. For lesions not
visible, the bronchoscope is
wedged in the respective
segment, and washings are
aspirated. For tumors
diagnosed on sputum
cytology but remaining
radiographically and
endobronchially invisible,
washings of each segment
can be performed for
localizing the tumor.
31623,
bronchoscopy
with brushing
or protected
brushing
Bronchial brushings: The Diagnosing malignancy and
brush is passed through the cell type, or diagnosis of
channel of the bronchoscope pneumonia.
and advanced to the lesion
either under direct
visualization or for peripheral
lesions under fluoroscopic
guidance. The lesion is
gently brushed and then the
brush is withdrawn through
the channel. Alternatively,
the brush may be left in the
channel and the entire
Cellular material,
brushings
bronchoscope withdrawn
(facilitated by the use of an
endotracheal tube) although
the diagnostic yield is no
greater.
The material is then
transferred onto glass slides
be pressing the brush onto
the slide using either a
circular or back and forth
motion. Another method for
processing brush specimens
involves agitating the brush
in a tube of isotonic solution.
31623 continued
Like biopsy forceps, almost
all brushes are disposable
(again, to reduce the
probability of breakage and
an iatrogenic foreign body left
in the airway). Brushes may
have bristles of different
lengths, ranging from 1 to 7
mm. Most bronchoscopists
choose brushes with a bristle
length of 3 to 4 mm, as the
specimens obtained seem to
be adequately cellular and
with less trauma to the tissue
than with brushes which have
shorter, stiffer bristles.
Brushes may be withdrawn
through the bronchoscope
channel or the bronchoscope
and the brush may be
removed as a single unit.
Pulling a brush through a
bronchoscope tends to strip
away some of the cellular
material, but it does not
significantly reduce the
probability of making a
cytologic diagnosis of cancer.
The term "brush biopsy of the -lung" is actually a misnomer.
The procedure is performed
intrabronchially and samples
are taken from within the
bronchus and not the alveolar
or lung tissue. Bronchial
and/or lung brushings are not
performed as an open
procedure (i.e., nonendoscopically). This is
different from a transbronchial
biopsy where the
bronchoscopy forceps
actually puncture the terminal
bronchus and samples of the
peribronchial alveoli tissue
are taken.
31623 continued
Protected Brushings:
-Bronchoscopy and protected
brushings is performed using
a brush that is sealed in a
catheter. The catheter is
passed through the
bronchoscope once it is in
place and inserted into an
area of diseased lung, often
using fluoroscopic guidance.
The brush is then advanced
beyond the catheter to obtain
--
uncontaminated material for
study and culture.
Protected brushings involve
passing a catheter through
the bronchoscope into an
area of diseased lung, often
using fluoroscopic guidance.
The catheter seal is broken
and an uncontaminated
brush is then advanced
beyond the catheter to obtain
specimens for culture and
sensitivity; or, an unprotected
brush is used to take
samples for cytology and
microscopic examinations.
Several passes of the
unprotected brush may be
required and is included in
the overall procedure.
31624,
Bronchoscopy;
with bronchial
alveolar lavage
Using bronchial alveolar
lavage (BAL) allows the
recovery of cells as well as
noncellular components from
the epithelial surface of the
lower respiratory tract. This
differs tremendously from
"washings," which refer only
to the aspiration of secretions
or small amounts of instilled
saline from larger airways.
Bronchial alveolar lavage
allows the recovery of cells
as well noncellular
components from the
epithelial surface of the lower
respiratory tract. This differs
significantly form ‘washings’,
which refer only to the
aspiration of secretions or
small amounts of instilled
saline form larger airways.
Bronchial alveolar lavage
involves repeated instillation
of sterile saline occurring in
aliquots with aspiration into
one or more containers.
Sequential and separate
aspirations are numbered for
laboratory testing.
31624 continued
Even though physiologic
saline had been used to
Assessing the activity of
Aspirated fluid,
alveolitis in chronic interstitial lavage.
lung disease or uncovering
the etiology of opportunistic
pneumonia (e.g., in AIDS).
Coding Tip:
See code 32997 for total lung
lavage not performed via
bronchoscopy. This code
does not involve an incision or
puncture of the pleural cavity.
(Source: CPT Assistant
newsletter, February 1999,
page 9).
--
--
wash the lungs and remove
secretions for many decades
with rigid bronchoscopes, it
was not until well after the
flexible bronchoscope had
been introduced that BAL
became an important clinical
and investigational tool. The
theory behind BAL is that
cells which line the alveoli, as
well as noncellular materials
such as cytokines, can be
recovered by aspirating fluid
that has been instilled into a
peripheral bronchus.
Example of a BAL
Technique:
For the sample to be
representative of the alveoli
themselves, it is important to
avoid biopsies and brushings
until after BAL is completed.
Airway secretions should be
gently aspirated first; the
bronchoscope channel
should be rinsed, and the
suction trap should be
changed. After this
preparation, the tip of the
bronchoscope is wedged into
the desired segmental or
sub-segmental bronchus. If
the disease process is
localized, the bronchus
chosen should conform to the
involved area and be
confirmed fluroscopically
whenever possible. With
diffuse pulmonary diseases,
the middle lobe, lingula, or
lower lobes are usually
chosen, as the volume of
fluid recovered is typically
greater than when upper
lobes are lavaged.
31624 continued
Generally, aliquots of 20 mL -of 0.9% saline are infused,
and suction with 50 to 80 mm
Hg negative pressure is
applied. A total of 100-300
mL is usually instilled, and
the return volume is usually
40% to 60% of the amount
instilled. If the wedge
--
position has been maintained
during lavage, there will be
little leakage back into the
more proximal airways and
little or no coughing during
the lavage itself.
Furthermore, the limit of
negative pressure application
helps to avoid trauma with
contamination of the
specimen by blood and
excess collapse of the
airways distal to the wedged
position so that return
volumes are inadequate.
The methods of processing
BAL fluid vary among
institutions. When BAL is
performed for clinical
diagnostic purposes alone,
the fluid is usually separated
into aliquots and submitted
for various microbiologic and
cytologic preparations.
Although it should be
transported promptly to the
appropriate laboratories, no
other special procedures are
required. When BAL is
performed with research
intent, however, it is
important to follow a specific
protocol for the results to be
valid and reproducible.
31625,
bronchoscopy
with bronchial
or
endobronchial
biopsy(s)
Endobronchial biopsy:
The bronchoscope is passed
transnasally or transorally in
the usual manner. Biopsy
forceps are passed down the
bronchoscope channel. The
forceps are then positioned
next to the lesion, and the
jaws are opened and closed
on the tissue. The biopsy
forceps are removed through
the channel of the
bronchoscope, or the entire
bronchoscope is pulled out
through an endotracheal tube
without passing the forceps
through the bronchoscope
channel.
The tissue is then gently
Obtaining diagnostic yield for Endobronchial
malignant neoplasm;
tissue, biopsy
diagnosing endobronchial
specimen
sarcoid granulomatous
infection, polyps and benign
tumor.
Bronchial mucosal biopsies
are taken by direct vision and
can be reported only once
(31625) even if performed at
different anatomic sites.
Coding Tip:

Code 31625 should
be reported only once
for a bronchoscopy
with endobronchial
eased out of the forceps and
transferred into a container
with formalin for fixation. For
large pieces of tissue that
cannot be passed through
the bronchoscope channel,
continuous suction can be
applied and the entire
bronchoscope can be
withdrawn to retrieve the
specimen.
31628,
bronchoscopy
with
transbronchial
lung biopsy(s),
single lobe,
with or without
fluoroscopic
guidance
biopsies of three
sites. This code is
intended to be
reported once,
regardless of whether
one or more biopsies
are performed on a
single site or multiple
sites. (Source: June
2004 CPT Assistant
newsletter, AMA,
Chicago, IL).
Bronchoscopy,
Diagnosing both malignant
transbronchial biopsy:
and nonmalignant lung
This procedure is the same disease
as for fiberoptic
bronchoscopy. The
bronchoscope is directed
toward the segment or the
area where the biopsy is to
be taken. The biopsy forceps
are inserted into the channel
of the bronchoscope and
advanced into the respective
segment.
Although the forceps can be
advanced blindly until
resistance is met and the
biopsy is taken, it is generally
felt that the incidence of
pneumothorax is higher using
this technique; therefore
fluoroscopic guidance is
advisable. The forceps are
advanced until the lesion or
specific area of the lung is
encountered. The scope is
wedged in the respective
bronchial segment to
tamponade any bleeding as
the biopsy forceps holding
the specimen are withdrawn.
The patient is instructed to
take in a deep breath after
the forceps are advanced to
the target area. The forceps
jaws are opened and the
patient is instructed to
exhale. As this is occurring,
the open jawed forceps are
advanced slightly and closed,
obtaining a piece of tissue.
Multiple biopsies are usually
Bronchial or lung
parenchymal
tissue
taken. At the end of the
procedure, either fluoroscopy
or an expiratory chest x-ray
can be used to check for
pneumothorax.
31629,
bronchoscopy
with
transbronchial
needle
aspiration
biopsy(s), with
or without
fluoroscopic
guidance
31630,
Tracheal/
bronchial
dilation
Transbronchial needle
aspiration:
This procedure is carried out
during fiberoptic
bronchoscopy. A catheter
with a 22 gauge, 13 mm
hollow needle is inserted
through the channel of the
bronchoscope. Once the tip
of the catheter clears the
distal end of the
bronchoscope, the needle is
advanced into the airway
lumen and locked in place.
The needle is then directed
perpendicular to the
tracheobronchial wall
adjacent to the area to be
sampled. The needle
punctures the wall and is
advanced completely to the
hub. The guide wire is
removed and negative
pressure is applied using a
50ml syringe primed with a
small amount of normal
saline. The needle and
catheter are completely
withdrawn from the channel
of the scope, and the first
drop of the specimen is
placed directly onto a dry
slide and immersed in
fixative. The remaining
material is sent for cell block.
Generally the procedure is
repeated.
Tracheal/bronchial
dialation: A rigid or
flexible bronchoscope is
advanced to the stenotic
area. A dilation catheter is
placed through the
bronchoscope into the
opening of the focal
stenosis and under
fluoroscopy is threaded
Histological staging of
bronchogenic carcinoma,
diagnosing suspected
peribronchial carcinoma
Coding Tips:
Assign 31629 when a
bronchoscopy with
transbronchial or ranscarinal
needle aspiration biopsy is
performed.
Stifcore aspiration needle is
used to obtain bronchial
biopsies.
Aspirated cellular
material or biopsy
specimen
distally to just beyond the
focal stenosis. (Source:
August 2005 CPT
Assistant newsletter,
AMA, Chicago, IL).
Tracheal/bronchial
stenting: A rigid or
flexible bronchoscope is
advanced to the stenotic
area. A dilator catheter is
placed through the
bronchoscope into the
small opening in the tumor
mass and is threaded
distally to just beyond the
tumor mass; under
fluoroscopy. The dilating
catheter is removed and a
guidewire is inserted
through the bronchoscope
into the now patent
trachea. The bronchoscope
is removed, leaving the
guidewire in place, and the
stent catheter is
manipulated over the
guidewire into the
previously stenotic area.
The bronchoscope is again
inserted and the area is
visualized both through the
bronchoscope and by
fluoroscopy. (Source:
August 2005 CPT
Assistant newsletter,
AMA, Chicago, IL).
31631, 31636,
31637, 31638,
bronchoscopic
stent therapy
Patients with non-resectable
airway obstruction from
benign or malignant disease
or bronchial anastomotic
stenosis following lung
transplantation are eligible for
endobronchial stent therapy.
In the second case of
anastomotic stenosis
following transplantation,
granulation tissue (often
associated with ischemia or
prior infection) at the
anastomotic site is removed,
and a stent is inserted to
maintain airway patency and
maximal luminal diameter.
Prior to the development of
endobronchial stent therapy,
chemotherapy and/or
radiation to reduce tumor
size and open the obstructed
airway was the only
therapeutic option available.
(Source: CPT Changes: An
Insider’s View 2005, AMA,
Chicago, IL, 2004).
31632,
bronchoscopy
with
transbronchial
lung biopsy(s),
each additional
lobe
with or without
fluoroscopic
guidance
Transbronchial lung biopsies
which are lung biopsies taken
peripherally with fluoroscopic
guidance of the biopsy
forceps and, importantly,
when taken from different
lobes, represent new
procedures with independent
risk factors, including biopsy
forceps location of the lesion,
bleeding, pneumothorax, air
embolism, etc..
The possible biopsy sites for
a bronchoscopic biopsy
include: the upper airway,
which extends from the vocal
cords to the lobar bronchi;
and each of the five lobes of
the lungs and their bronchi;
the right upper, middle, and
lower lobes; and the left upper
and lower lobes.
31633,
bronchoscopy
with
transbronchial
needle
aspiration
biopsy(s), each
additional lobe
with or without
fluoroscopic
guidance
Transbronchial needle
aspiration biopsies which are
taken centrally by penetration
of a large airway with a
specially designed biopsy
needle and aspiration of a
lymph node or central mass
lesion. This represents a less
invasive approach which
otherwise would require an
invasive surgical approach
with the attendant additional
risks of an open approach
procedure.
The possible biopsy sites for
a bronchoscopic biopsy
include: the upper airway,
which extends from the vocal
cords to the lobar bronchi;
and each of the five lobes of
the lungs and their bronchi;
the right upper, middle, and
lower lobes; and the left upper
and lower lobes.
31641,
-bronchoscopy
with destruction
of tumor or
relief of
stenosis by any
other excision
Coding Tips: For
-bronchoscopic photodynamic
therapy, report 31641 in
addition to 96570, 96571 as
appropriate
31643,
bronchoscopy
with catheters
for
There is not a separate code
for the removal of the
brachytherapy catheters.
This is not a separately
--
--
radioelement
application
reportable service.
Bronchoscopy, localized
Documenting radiographically -bronchogram: The
localized bronchiectasis in
bronchoscope is inserted in patients with recurrent
the usual manner. The area pneumonias of chronic
of suspected bronchiectasis
is either identified on chest xray or endobronchially. The
bronchoscope is wedged in a
lobar or segmental bronchus
or, using the bronchoscope,
a separate catheter is
placed. Dionisol is rapidly
injected through the
bronchoscope channel or
other tube and monitored
fluoroscopically. Still pictures
are taken as well.
Source: Diagnostic Procedure Handbook, Joseph A. Golish, MD, FACP, FCCP, Editor, Williams
& Wilkins, Baltimore, Md., 1992; Chicago, IL, Nov. 11-13, 1998, Presenter: Bronchoscopic
Biopsies and Bronchoalveolar Lavage, Paul A. Kvale, MD, Chest Surgery Clinics of North
America, Volume 6, Number 2, May 1996; CPT 1999 Coding Symposium, Walter J. O’Donohue,
MD is chief of pulmonary and critical care medicine at Creighton University School of Medicine in
Omaha, Nebraska; CPT Changes 2004 – An Insider’s View, AMA, Chicago, IL, 2003; CPT
Changes: An Insider’s View 2005, AMA, Chicago, IL, 2004; August 2005 CPT Assistant
newsletter.
31656,
bronchoscopy
with injection of
contrast
material for
segmental
bronchography