Chapter 15
Respiratory System (30000 – 32999)
Nose (30000 – 30999)
Incision – 30000 – 30020 (pg 451 SBS TB)
Look for location of the abscess and the approach
Excision (pg 147 CPT Bk) – 30100 – 30160
 Note: When 2 procedures are completed during the same surgical session,
code the most complex procedure first.
 30100 – for a biopsy performed intranasally
Nasal Polpectomy (pg 147 CPT) – 30110 or 30115
 If the surgeon performs the total ethmoidectomy on the patient’s right side
and removes a polyp from the left ethmoid, you may report 31257-59 in
addition to the ethmoidectomy 31255.
 Note: Modifier -50 is assigned when the polpys are removed from both the
left and right sides of the nose.
Inferior Turbinate Procedures (pg 147 CPT) – 30130 – 30930.
Note: you can only bill one turbinate procedure per turbinate. Unilateral (RT or LT).
 Note: You can bill inferior turbinate fracture, excision, and resection
bilaterally, but report cautery only once, no matter how many sides the
physician addresses.
 An excision (30130) describes the removal of all or part of the turbinate.
Introduction (pg 147 CPT) – 30200 - 30220
 Nasal Button (30220) pg 147 CPT Book, pg 454 SBS TB
o Used for patients who have perforated septum
o Used on patients who pick holes in their nose
Removal of Foreign Body (pg 147 CPT)(pg 454 SBS TB) – 30300 - 30320
 Ex. A 4-yr old pt presents with a rock in her nose that her mother is unable to
extract. The doctor removes it without anesthesia. Code 30300, don’t bill OV
because the mother already had identified the problem. However, if the
provider has to put the patient out in order to remove the rock, use 30310.
Repair (pg 147 CPT) (pg 454 and 455 SBS TB) – 30400 – 30630
Rhinoplasty (30400 – 30462)
 Cosmetic purpose – reduce the size of the patients nose by removing
cartilage
 Functional purpose – repair patients nose for breathing difficulties
 Providers need to indicate medical necessity
 30400 – for the first time a rhinoplasty was done
 30430 – when the rhinoplasty is done again
M. Cremers - 2010
Page 1
Chapter 15
Respiratory System (30000 – 32999)
Septoplasy (30520) pg 148 CPT, pg 455 SBS TB
 provider is usually repairing a deviated septum.
 Watch notes under CPT code
Destruction – 30801 – 30999pg 148 CPT, pg 455 SBS TB
 Abalation – removal by cutting
 Intramural – abalation of the deeper mucosa
 Superficial – abalation which involves the outer layer of mucosa
Other procedures (30901 – 30999) pg 148 CPT, pg 455 SBS TB)
 Used for the control of nasal hemorrhage
o Look for the type of control and the level of complexity
Accessory Sinuses (31000 – 31299) pg 188 CPT, pg 457& 458 SBS TB
 31000 - Lavage – sinuses are washed with saline which is put in a canula to
remove infection, use modifier -50 if done on both sides
 Sinusotomy – procedure in which the physician enlarges the passage or
creates a new passage from the nasal cavity into the sinus. Normally done
due to chronic sinus infections.
Caldwell-Luc Procedure (31030 – 31031) – pg 148 CPT - provider has to gain access to
and enter the maxillary sinuses through the gum for removal of polyp.
Sinus Endoscopies
 31231 – 31294 – unilateral (pgs 449, 450 SBS TB), pg 149-150 CPT
 Note: if sinus endoscopy is diagnostic, code states unilateral or bilateral
 Code to the full extent of the procedure
 Code the correct approach to the procedure
 If multiple endoscopies performed, use modifier -51
 Diagnostic sinus endoscopies are bundled into a surgical endoscopy, code the
surgical endoscopy as it has a higher value. However if diagnostic endoscopy
performed on one side and a surgical endoscopy on the left side, use RT/LT
modifiers
 Nasal endoscopic procedures are different from intranasal procedures
Ethmoidectomy (31200 – 31255) pgs 149 – 150 CPT
 removal of diseased tissue from the ethmoid sinuses to treat infection and
remove obstructions
o You can separately report a middle turbinectomy if the ENT performs it
on the opposite side of the nose from the ethmoidectomy.
M. Cremers - 2010
Page 2
Chapter 15
Respiratory System (30000 – 32999)
CSF Leak Repair (cerebrospinal fluid leak) (31290 – 31291),pg 150-151 CPT
Orbital Wall decompression (31292 – 31294) pg 151 CPT Book
 the bone surrounding the eye to treat conditions such as Grave’s disease Can
use -50 or RT/LT
Postseptoplasty Debridement (31237) pg 150 CPT – use modifiers 79 or 58 on
debridement code if done during the post op period of the Septoplasty.
Larynx (31300 – 31599) pg 151 CPT, pg 458-459 SBS TB
Note: The codes in the Laryngotomy category codes describe procedures in which the
surgeon performs a thyrotomy for the purpose of exposing the larynx
The codes in the Trachea and Bronchi subheading, incision category describe a
procedure in which the surgeon performs only the tracheostomy and the larynx is not
exposed.
 Laryngectomy (31360 – 31382) (pg 151 CP) – Most often performed to treat
patients for cancer.
 31360 – Laryngectomy for one side and 38724-59 for bilateral modified
radical neck dissection
 31365 – This code only covers a unilateral radical neck resection. If
performed on both side – use 31365 for first side and 38720-59 for second
side.
Keep in Mind: Laryngectomies always include permanent tracheostomies. Do not
report 31600. Also includes thyroidectomy.
Laryngoscopy (pg 152 CPT) - (31505 – 31579).
 29 procedures
 divided into the following 3 groups (indirect, direct, flexible)
 the groups are further broken down by function including but not limited to
(diagnostic, with biopsy, with removal of foreign body) (with removal of lesion)
 31520 – use when the ENT changes a tracheostomy tube before the fistula
track has become established. Confer with provider to find out when the
fistula tract becomes established.
o Note: For trach tube changes in the office, nursing home or bedside
after the fistula track has healed, you should consider the trach change
as a factor when deciding on a level of E/M.
Keep in Mind: If a procedure that began as an indirect or flexible laryngoscopy had to
be converted to a direct scope, you can only bill the direct scope.
M. Cremers - 2010
Page 3
Chapter 15
Respiratory System (30000 – 32999)
Note: Nasopharyngoscopy - pg 152 CPT
 92511 – examines the nasopharynx and the edge of the soft palate.
 31575 – examines the larynx
o If the clinician does not perform recording, report 92700. The
swallowing eval codes all include the flexible laryngoscopy and 31575
is NOT separately billable.
Laryngeal Web – 31580 (pg 152 CPT, pg 459 SBS TB)
 Performed in 2 stages
Trachea and Bronchi – 31600 – 31899 (pg 152 – 154 CPT), pg 460-461 SBS TB
 Tracheostomy (31600 – 31601)
o Note: Trach tube change – the tube change is usually considered part
of the E/M services. May be able to bill the supply (check local
policies)
 Watch the approaches
Introduction (31715-31730) pg 154 CPT Book, pg 462 SBS TB
 Report catheritization, instillation, injection and aspiration of the trachea
and the placement of tubes into the trachea
Excision and Repair (31715-31830) pg 154 CPT Book, pg 462 SBS TB)
 Include plastic repairs, such as tracheoplasty and bronchoplasty in
addition to the excision of stenosis of or tumors, the suturing of tracheal
wounds, and scar revision
Lungs and Pleura – 32035 – 32999
Incision (32035-32225) pg 154 CPT pg 463 SBS TB
 Thoracotomy – making a surgical incision into the chest wall and opening
the area to the view of the surgeon.
 The codes are divided according to the reason for the procedure
 Chest tubes are bundled into the procedures
Excision (32310-32405 pg 154 CPT, pg 463 SBS TB
 Contains codes for pleurectomy, biopsy, pneumonocentesis, removal, and
reconstructive lung procedures
 Note: Percutaneous needle lung or mediastinum biopsies are often performed
under radiologic guidance to the correct placement of the needle can be ensured.
M. Cremers - 2010
Page 4
Chapter 15
Respiratory System (30000 – 32999)
Removal (32420-32540) pg155 CPT, pg 463 and 464 SBS TB
 Pneumonocentesis (32420) – withdrawal of fluid from the long by means of an
aspirating needle.
 Codes for the removal of the lung are based on how much of the lung is removed
(32440-32540)
 Thoracentesis (32421-32422)
o Chest tube can be inserted to drain accumulating fluid (32551) pg 156
CPT
Introduction (32550-32553) pg 156 CPT
Destruction (32560-32562) pg 157 CPT
 Instillation of a fibrinolytic agent to break up the fluid
Endoscopy (32601-32856) pg 157 CPT, pg
 Thoracoscopy – inside of the chest cavity is examined through a fiberoptic
endoscope
Repair (32800-32856) pgpg 158 CPT
Lung Transplantation (32850-32856) pg 158 CPT
 3 components of physician work
o Cadaver donor pneumonectomy – harvest lung
o Backbench work – prep the cadaver donor single or double lung
o Recipient lung allotransplantation
Surgical Collapse Therapy; Thoracoplasty (32900-32960) pg 158 CPT, pg 465 SBS TB
 Thoracoplasty (32905-32906) – a portion of the internal skeletal support is
removed to treat a condition in which pus chronically collects in the chest
cavity. Code includes all stages
 Pneumonolysis (32940) – performed to separate the inside of the chest cavity
from the lung to permit the lung to collapse.
 Pneumothorax Injection – therapeutic procedure in which the surgeon inserts
a needle into the pleural cavity and injects air into the pleural cavity.
Other Procedures (32997-32999) (pg 158 CPT)
 Lung lavage (unilateral)
 Abalation therapy
M. Cremers - 2010
Page 5
Operative Report
Indications for Procedure: Pt is a 40-year old male who was involved in an MVA. He
is having some pulmonary insufficiency.
Procedure: Bronchoscope was inserted through the accessory point on the end of the
ET tube and was then advanced thru the ET tube. The ET tube came pretty close down
to the carina. We selectively intubated the RT main stem bronchus w/ the
bronchoscope. There were some secretions here, and these were aspirated. We then
advanced this selectively into first the lower and then the middle and upper lobes.
Secretions were present, more so in the middle and lower lobes. No mucous plug was
identified. We then went into the left main stem and looked at the upper and lower
lobes. There was really not much in the way of secretions present. We did inject some
saline and aspirated this out. We then removed the bronchoscope and put the patient
back on the supplemental O2. We waited a few minutes. The oxygen level actually
stayed pretty good during this time. We then reinserted the bronchoscope and went
down to the right side again. We aspirated out all secretions and made sure everything
was clear. We then removed the bronchoscope and pulled back on the ET tube about
1.5 cm. We then again placed the patient on supplemental oxygenation.
Findings: No mucous plug was identified. Secretions were found mainly in the right
lung and were aspirated. The left side looked pretty clear.
A. 31646 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed diagnostic, with cell washing, when performed (separate procedure)
with therapeutic aspiration of tracheobroncial tree, subsequent) (518.5
(Pulmonary insufficiency following trauma and surgery), E819.9 (MVA
unspecified nature, other specified person – pg 719) wasn’t a subsequent
procedure, but a primary procedure – eliminate)
B. 32654 , 518.82 (Other pulmonary insufficiency NEC), E812 (Other MVA involving
collision w/ motor vehicle – pg 716) (36254 does not exist - eliminate)
C. 31645-50 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed diagnostic, with cell washing, when performed (separate procedure),
with therapeutic aspiration of tracheobronchial tree, initial (eg. Drainage of lung
abscess) 518.5 (Pulmonary insufficiency following trauma and surgery), E819.9
(MVA unspecified nature, other specified person – pg 719) (indicates same
procedure done on both sides and it wasn’t – eliminate)
D. 31645-RT (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed diagnostic, with cell washing, when performed (separate procedure),
with therapeutic aspiration of tracheobronchial tree, initial (eg. Drainage of lung
abscess) 31622-51LT (Bronchoscopy, rigid or flexible, including fluoroscopic
guidance, when performed diagnostic, with cell washing, when performed
(separate procedure), 518.5 (Pulmonary insufficiency following trauma and
surgery), E988.5 (Injury by crashing vehicle, NOS)
M. Cremers - 2010
Page 6
This 52-year old has undergone several attempts at extubation, all of which failed. He
also has morbid obesity and significant subcutaneous fat in his neck. The patient is
now in for a flap tracheostomy and cervical (around your neck area) lipectomy. The
cervical lipectomy is necessary for adequate exposure and access to the trachea and
also to secure tracheotomy tube placement. Assign code(s) for the physician service
only.
A. 31610, 15839-51 (Excision, excessive skin and subcutaneous tissue (includes
lipectomy; other area – op report indicates surgical area - eliminate)
B. 31610 (only indicates the flap tracheostomy – eliminate)
C. 31610, 15838 (..submental fat pad - Submental Lipoplasty Double chin surgery)
D. 31630 (…with tracheal/bronchial dilation or closed reduction of fracture –
eliminate – no fracture mentioned), 15839-51
Operative Report:
The patient is in for a bone marrow biopsy. The pt was sterilized by standard
procedure. Bone marrow core biopsies were obtained from the left posterior iliac crest
with minimal discomfort. At the end of the procedure, the pt denied discomfort, without
evidence of complications. The pt has diffuse (to break up and distribute or not
concentrated or localized), malignant lymphoma. Assign codes for the physician
service only.
A. 20225, 229.0 (Benign neoplasm of lymph nodes – eliminate, not malignant)
B. 38221 (bone marrow biopsy), 202.80 (Other malignant lymphoma – lymph nodes
of multiple sites) – pg 230
C. 38230, 200.10 (Lymphosarcoma, unspecified site – eliminate, site specified)
D. 38220 (aspiration – bundled into bone marrow biopsy – eliminate), 202.80
M. Cremers - 2010
Page 7
Operative Report
Preoperative Diagnosis: Atelectasis of the left lower lobe
Procedure Performed: Fiberoptic bronchoscopy with brushings and cell washings
Procedure: The patient was already sedated, on a ventilator and intubated; so his
bronchoscopy was done through the ET tube. It was passed easily down to the carina
(know this word) about 2 to 2.5cm above the carina, we could see the trachea, which
appeared good, as was the carina. In the right lung, all segments were patent and
entered, and no masses were seen. The left lung, however, had petechial ecchymotic
areas scattered throughout the airways. The tissue was friable and swollen, but no
mucous plugs were noted, and all airways were open, just somewhat swollen. No
abnormal secretions were noted at all. Brushings were taken as well as washings,
mucous plug, but nothing really significant was returned. The specimens were sent to
appropriate cytological and bacteriological studies. The pt tolerated the procedure fairly
well.
A. 31622, 31623-51, 518.0 (Atelectasis) – eliminate – separate procedure (RT,LT,
lobes can be distinguished as the right and left side, versus being bilateral)
B. 31623, 770.4 (Primary atelectasis – eliminate, incorrect dx)
C. 31622-RT ((Bronchoscopy, rigid or flexible, including fluoroscopic guidance,
when performed diagnostic, with cell washing, when performed (separate
procedure), 31623-51LT, 518.0
D. 31624 (…with bronchial alveolar lavage – pg 153), 770.4 (eliminate – incorrect
dx)
Note: In anatomy, the carina is a cartilaginous ridge within the trachea that runs
anteroposteriorly between the two primary bronchi at the site of the tracheal bifurcation
at the lower end of the trachea. Tracheobronchial injury, an injury to the airways,
occurs within 2.5 cm of the carina 40–80% of the time.
The ridge separating the openings of the right and left main bronchi at their junction with
the trachea.
Synonym(s): carina tracheae TA, tracheal carina
M. Cremers - 2010
Page 8
M. Cremers - 2010
Page 9