Respiratory System List

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Respiratory System

Chapter Topics
Format
Endoscopy
Nose
Accessory Sinuses
Larynx
Trachea/Bronchi
Lungs and Pleura



Learning Objectives
After completing this chapter you should be able to
1

Differentiate between services reported with codes from the Respiratory System subsection and those reported with codes from other subsections

2

Explain the effects of extent and approach when reporting endoscopy respiratory procedures

3

Identify highlights of nasal procedure coding

4

Analyze the codes to report services to the accessory sinuses

5

Categorize the codes in the Larynx subheading

6

Explain the structure of the trachea/bronchi codes

7

Distinguish the difference amongst the codes assigned to report lungs and pleura services, and procedures

8

Demonstrate the ability to code respiratory services and procedures

FORMAT

The Respiratory System subsection is arranged by anatomic site (e

, nose, accessory sinus, larynx) and then by procedure (e

...

, incision, excision, introduction)

...

Your knowledge of respiratory terminology is important (Fig

...

20-1), as you assign codes from the Respiratory System subsection

...

In the Musculoskeletal System subsection, arthroscopy codes are placed at the end of the subsection, but in the Respiratory System subsection, the endoscopy codes are listed throughout, according to anatomic site

...

Fracture repair, such as that of the nose or sternum, is listed in the Musculoskeletal System subsection, not in the Respiratory System subsection

...

Procedures that are performed on the throat or mouth are not located in the Respiratory System subsection but instead are located in the Digestive System subsection

...

The Respiratory System subsection contains some codes that may be considered cosmetic

...

It is important to note each of the components performed during the procedure because there are many services bundled into some of these codes

...

For example, under the subheading Nose and the category Repair, there is code 30400 for rhinoplasty

...

The rhinoplasty may be performed either through external skin incisions (open) or through intranasal incisions (closed), and both approaches can be reported with 30400

...

The extent of the procedure varies based on the desired outcome, but a rhinoplasty can include fracturing a deformed septum, repositioning the septum, reshaping and/or augmenting the nasal cartilage, removing fat from the area, performing a layered closure, and applying a splint or cast

...

If all of these components of a rhinoplasty were performed, they would be bundled into 30420

...

You have to read all of the notes and the code information carefully to ensure that you do not code components of the procedure separately if there is one code that includes all the components

...

Nasal cavity
Nasal conchae
Nose
Larynx
Trachea
Primary bronchus
Secondary bronchi
Bronchioles
Right lung

Left lung
Diaphragm
Nasopharynx
Oropharynx
Epiglottis
Laryngopharynx
Esophagus


ENDOSCOPY

During endoscopic procedures, a scope is placed through an existing body orifice (opening), or a small incision is made into a cavity for scope placement

When sinus endoscopies are performed, a scope is placed through the nose into the nasal cavity

...

Codes for sinus endoscopy (31231-31294) report unilateral (on one side) procedures except in the case of a diagnostic nasal endoscopy, which is unilateral or bilateral

...

Multiple procedures may be performed within different sinuses (frontal, maxillary, and ethmoid sinuses) during the same operative session

...

The CPT manual has combined into a single code some multiple sinus procedures commonly performed at the same operative session

...

Endoscopic procedures may start at one site (such as the nose) and follow through to another site (such as the larynx or bronchial tubes)

...

It is important to choose the code that most appropriately reflects the furthest extent of the procedure

...

For example, if a direct laryngoscopy is performed, and the scope is progressed past the larynx and includes examination of the trachea, the service is reported with 31515 because the code description states either with or without tracheoscopy

...

However, if it is necessary to continue the procedure to the bronchial tubes, the service would be reported with 31622 (bronchoscopy)

...

The larynx and trachea must be passed to get to the farthest point (bronchial tubes)

...

In these instances, it is the full extent of the procedure that determines the code assignment

...

The same surgical procedure may be performed using different approaches

...

For example, code 32141 describes a thoracotomy with "resection-plication (removal/shortening) of bullae (blisters)

...

includes any pleural procedure, when performed

...

" Code 32655 describes a surgical thoracoscopy with resection-plication of bullae, includes any pleural procedures when performed

...

Code 32655 describes the same procedure as 32141, except that 32655 is a procedure performed through very minute incisions utilizing a thoracoscope, whereas code 32141 describes an open incision through the thorax, opening the full operative site to the surgeon

...

In these instances, it is the approach utilized to perform the procedure that determines the code assignment

...

Example
31276

Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus

CAUTION Code to the full extent of the procedure

CAUTION

Code the correct approach for the procedure

Multiple endoscopic procedures may be performed through the same scope during the operative session

...

When this occurs, each procedure should be reported with modifier -51 (multiple procedures) placed on subsequent procedure(s)

...

For example, a bronchoscopy with biopsy is performed as well as a bronchoscopy with removal of a foreign body

...

Not only would you report a bronchoscopy with biopsy, but you would also report the removal of a foreign body

...

The multiple procedure modifier -51 would be placed after the lower priced (least resource-intensive) procedure

...

The exception to this occurs when the CPT manual offers a code for which the description includes all the separate elements of the procedure bundled into one code

...

Remember that a diagnostic endoscopy is always bundled into a surgical endoscopy

...

For example, if a physician began a diagnostic endoscopic nasal procedure and continued on to complete a surgical procedure, you report only for the surgical procedure

...

To report both a diagnostic and a surgical nasal endoscopy is unbundling if the diagnostic and surgical procedures are performed on the same nasal space

...

However, if a diagnostic sinus endoscopy is performed on the right maxillary sinus and a surgical endoscopic maxillectomy on the left, both procedures are reported with appropriate -LT and -RT modifiers because two different procedures were performed

...

When reporting laryngoscopic procedures, note that the terms "indirect" and "direct" are often stated in the code description

...

For example, locate codes 31505, indirect, and 31515, direct in the CPT manual

...

Indirect in 31505 means that the physician used a tongue depressor to hold the tongue down and view the epiglottis (the lid that covers the larynx) with a mirror

...

The patient vocalizes (says "ah") and the physician can then view the vocal cords

...

Direct in 31515 means that the endoscope is passed into the larynx and the physician looks directly at the larynx through the endoscope

...

The operative report will indicate whether the procedure was indirect or direct

...

Locating Endoscopy Codes

...

...

Endoscopy codes can be located in the CPT manual index under "Endoscopy" and then under the anatomic subterm of the site

You can also locate an endoscopic procedure by the anatomic endoscopy title

...

For example, a bronchial biopsy using endoscopy is listed under "Bronchoscopy" and then under the subterm "Biopsy

...

"

CAUTION

Do not confuse nasal/sinus endoscopic procedures with intranasal procedures

Intranasal procedures may require that surgical instruments be placed into the nose but do not require the use of an endoscope

...

When an endoscope is used in a nasal/sinus procedure, assign a nasal/sinus endoscopy code

...

NOSE

Many of the codes in the Nose subheading are reported by physicians who specialize in treating conditions of the nose (otorhinolaryngologist

ear, nose, and throat specialists), but there are also many codes in the subheading that are more widely used

...

For example, it is in the Nose subheading that you will locate codes for commonly performed office procedures, such as control of nosebleeds, incision of abscesses, removal of foreign objects from the nose (think children!), and removal of nasal cysts and lesions

...

Incision

Codes for incision of a nasal abscess (30000, 30020) are divided on whether the abscess is on the nasal mucosa or the septal mucosa

If a nasal abscess is approached from the outside of the nose (external approach), you would assign a code from the Integumentary System subsection

...

but if the approach is from the inside of the nose (internal approach), you would assign
a code from the Respiratory System subsection

...

The medical record will describe the approach to the procedure

...

After an abscess has been penetrated, the physician may close the area immediately or place a tube in the incision to ensure that the pus continues to drain from the abscess area

...

After the drain is removed, the abscess may be packed with gauze, with one end of the packing material left outside the surface to act as a wick, as illustrated in Fig

...

20-2, A-C

...

The insertion and removal of the tube and/or gauze and any required sutures and/or anesthesia are bundled into the code, so you should not report these services separately

...

You should report any additional supplies over and above those usually used for the procedure by using the Medicine section code for supplies, 99070, or a HCPCS code, as directed by the third- party payer

...

Excision

Within the Nose subheading, the Excision category (30100-30160) contains a wide range of procedures that describe removal of tissue from the nose—for example, biopsy, polyp excision, and cyst excision—as well as resection of the turbinate bone

CODING SHOT
When two procedures are completed during the same surgical session, the most complex procedure is sequenced first

...

The biopsy code (30100) reports a biopsy that is performed intranasally

...

but if the procedure was for a biopsy of the skin outside of the nose, you assign the biopsy code 11100 from the Integumentary System

...

Nasal polyps develop and mature, causing nasal obstruction (Fig

...

20-3, A)

...

The physician removes the polyps, usually with a snare, as illustrated in Fig

...

20-3, B

...

The excision of nasal polyps is reported with one of two codes (30110 and 30115)

...

The difference between the codes is the extent of the excision

...

Code 30110 reports a simple polyp excision that would usually be performed in the office, whereas 30115 reports a more extensive polyp excision that would usually be performed in a hospital setting

...

CODING SHOT
Modifier -50 (bilateral) is assigned when the polyps are removed from both the left and right sides of the nose

...

The codes for excision or destruction of lesions inside the nose are divided based on the approach—internal or external

...

Usually, if the approach to the procedure is external, you are referred to the Integumentary System subsection to locate the correct code

...

but the nasal lesion excision/ destruction codes can be assigned for either an external or an internal approach to a lesion

...

You have to read the code descriptions carefully to ensure that you understand all of the circumstances that surround assignment of the code, and you have to identify codes such as the lesion excision/destruction that are exceptions to the usual rules

...

All methods of lesion destruction, including laser, are included in the Excision codes

...

Usually, if laser was used in the destruction of a lesion, you would be referred to a separate set of codes just for laser destruction

...

but with the lesion destruction codes in the Nose category, laser is included as one of the destruction methods

...

Turbinates are the bones on the inside of the nose

...

These bones are shaped like a spiral shell and humidify, warm, and filter the air

...

These bones are referred to as the nasal conchae

...

The turbinates are divided into three sections—inferior, middle, and superior (Fig

...

Portions of or all of a turbinate bone may be removed because of chronic congestion or neoplastic growth

...

Because third-party payers usually do not pay for cosmetic surgical procedures, you must document the medical necessity for noncosmetic procedures carefully to ensure appropriate reimbursement

...

Watch for and read the extensive notes inside the parentheses throughout this category

...

Superior, inferior, and middle nasal turbinates

Middle nasal turbinate and meatus
Soft palate
Superior nasal turbinate and meatus
Inferior nasal turbinate and meatus
Atrium of middle meatus
Vestibule Hard palate




Introduction
Introduction codes (30200-30220) include injection, displacement therapy, and insertion

...

Injections into the turbinates (30200) are therapeutic injections usually performed to shrink the nasal tissue to improve breathing

...

For example, if a patient has inflamed nasal passages due to an allergic reaction or a deviated septum, the patient may benefit from a steroid injection into the turbinates

...

Displacement therapy (30210) is a procedure in which the physician flushes saline solution into the sinuses to remove mucus or pus

...

The insertion of a nasal button (30220) (as illustrated in Fig

...

20-5) is a technique used for a patient who has a perforated septum

...

The physician places the button into the opening and fastens the button in place with sutures

...

The button is usually made of silicone or rubber

...

This technique is used as a method of repairing the septum without surgical grafting

...

Removal of a Foreign Body
A variety of objects are inserted into the various orifices (openings) of the body, and the nose is a common place into which these foreign objects are placed

...

The code to report an office procedure for the removal of a foreign body from the nose is 30300

...

Codes for more extensive procedures are also available for removal of foreign objects from the nose, such as those requiring general anesthesia (30310) and a more invasive surgical procedure

...

Repair
Within the Repair category (30400-30630) are the plastic procedures— rhinoplasty, septoplasty, and septal dermatoplasty

...

Rhinoplasty is a procedure to reshape the nose internally, externally, or both

...

The codes are divided based on the extent (minor, intermediate, major), on whether the septum was also repaired (septoplasty), and on whether the procedure was an initial or secondary procedure

...

Secondary procedures are those that are performed after an initial procedure

...

For example, if a rhinoplasty was performed and the results were not as successful as the patient desired, the surgeon could perform a second procedure (secondary) to improve the result

...

Septoplasty is rearrangement of the nasal septum

...

This procedure is commonly performed due to a deviated septum

...

Destruction
Destruction can be accomplished by use of ablation

...

Ablation is removal, usually by cutting

...

Ablation or cauterization is performed to remove excess nasal mucosa or to reduce inflammation

...

The destruction codes (30801, 30802) are divided according to the extent of the procedure—superficial or intramural

...

Intramural is ablation of the deeper mucosa, as compared to superficial ablation, which involves only the outer layer of mucosa

...

CAUTION

Do not use a septoplasty code if the operative report indicates that only a resection of the inferior turbinate(s) was performed

The resection of the inferior turbinate(s) is reported with 30140 and is not a procedure performed on the septum

...

The septoplasty code, 30520, is reported when the nasal septum is resected

...

There is a note enclosed in parentheses following both codes—30140 and 30520—that cautions you to use the correct code, depending on whether the turbinate or the septum was resected

...

Other Procedures
Codes (30901-30920) for the control of nasal hemorrhage are located in the Other Procedures category and are often reported

...

The physician may use anterior or posterior pressure to control the hemorrhage

...

Anterior nasal packing (Fig

...

20-6) is the application of pressure using packing to the anterior aspect of the nasal cavity, and posterior nasal packing is the application of pressure to the posterior aspect of the nasal cavity

...

The nasal pack is inserted via the nasal opening

...

A balloon may be inserted and inflated to further control bleeding (Fig

...

The codes are divided according to the type and extent of control required

...

CODING SHOT
The key to correctly coding nasal hemorrhage is to know the type of control (anterior/posterior) and the level of complexity (simple/ complex) utilized by the physician to control the hemorrhage

...

There are times when neither cauterization nor packing will control a nasal hemorrhage, and ligation of the bleeding artery is required

...

Ligation of ethmoidal arteries involves opening the upper side of the nose and locating and tying the ethmoid artery (Fig

...

Ligation of the internal maxillary artery is performed to gain control of nasal hemorrhage by locating and ligating the maxillary artery (Fig

...

A therapeutic fracture of the nasal turbinate is a procedure in which the physician fractures the turbinate bone and then repositions it, under local anesthetic

...

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