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