How can we help?

You can also find more resources in our Help Center.

633 terms

Respiratory System List

STUDY
PLAY
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
g
...
, nose, accessory sinus, larynx) and then by procedure (e
...
g
...
, 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
...
20-4)
...
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
...
20-7)
...
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
...
20-8)
...
Ligation of the internal maxillary artery is performed to gain control of nasal hemorrhage by locating and ligating the maxillary artery (Fig
...
20-9)
...
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
...
Repositioning the turbinate(s) often alleviates obstructed airflow caused by enlarged inferior turbinates or a previous fracture that has healed out of alignment and resulted in a deviation of the nose
...
...
FIGURE Superior view Ethmoid artery

Anterior ethmoidal artery
Posterior ethmoidal artery

FIGURE Maxillary artery
...
Maxillary artery




ACCESSORY SINUSES

Incision
Within the Incision category are codes for services that you would not think of as being incisional
For example, the nasal sinuses can be washed (lavage) with a saline solution introduced through a canula (hollow tube) to remove infection
...
The Incision category code 31000 describes lavage of the maxillary sinus
...
Lavage can be performed on both the maxillary and the sphenoid sinuses (Fig
...
20-10)
...
If the lavage is of the sphenoid sinus, you report 31002
...
CODING SHOT
Use modifier -50 (bilateral) when the lavage is performed on both the left and right maxillary sinuses
...
Many of the codes in the Incision category are for sinusotomies
...
A sinusotomy is a procedure in which the physician enlarges the passage or creates a new passage from the nasal cavity into a sinus
...
This procedure is usually performed due to chronic sinus infection
...
the procedure improves sinus drainage
...
The codes are divided according to the extent of the procedure
...
FIGURE Paranasal sinuses
...
Frontal sinus
Ethmoid sinus
Sphenoid sinus
Maxillary sinus



LARYNX
The procedures reported with codes in the Larynx subheading (31300-31599) include a wide range of surgical procedures, such as laryngectomy, plastic repair, and nerve destruction
Excision
Laryngotomy is an incision that is made over the larynx (thyrotomy) to expose the larynx to view
With the larynx exposed, the surgeon can remove a tumor, a laryngocele (air-filled space), or a vocal cord (cordectomy)
...
A laryngotomy can also be performed for diagnostic purposes, without a surgical procedure being performed
...
Be careful not to get the codes from the Laryngotomy category confused with the tracheostomy codes located in the Trachea and Bronchi subheading, Incision category, which you will learn more about later in this chapter
...
The codes from the two categories differ, depending on the purpose of the procedure
...
The Laryngotomy category codes describe procedures in which the surgeon performs a thyrotomy (incision of the larynx through the thyroid cartilage) 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, usually to establish airflow, and no procedure or exposure of the larynx is planned or is involved
...
Radical neck dissection, as referred to in the codes for laryngectomy, is the removal not only of the larynx but also of lymph glands and/or other surrounding tissue
...
Many of the codes in the Larynx subheading, Excision category are divided according to whether radical neck dissection was or was not performed
...
The operative report would indicate the extent of the dissection by referring to excision of lymph nodes in a radical procedure
...
Introduction
Intubation is the establishment of an airway
The intubation represented in 31500 is provided on an emergency basis at such time as the patient experiences respiratory failure or the occurrence of an inadequate airway
...
Fig
...
20-11 illustrates endotracheal intubation
...
The other Introduction code (31502) is for the replacement of a previously inserted tracheotomy tube
...
Repair
Within the Repair category are several plastic procedures
A laryngoplasty for a laryngeal web is a surgical procedure, usually performed in two stages, for the repair of congenital webbing between the vocal cords
...
The surgeon removes the webbing and places a spacer between the vocal cords
...
At a later time, the surgeon will again expose the vocal cords, using the same tracheostomy incision made on the initial procedure, and remove the spacer
...
TRACHEA/BRONCHI
Procedures in the Trachea and Bronchi subheading (31600-31899) include incisions, introductions, and repairs, in addition to the endoscopic procedures
Incision
Tracheostomy is the most common procedure reported with codes from the Incision category
A tracheostomy can be planned or performed as an emergency procedure
...
A planned tracheostomy is usually performed when there is a need for prolonged ventilation support, beyond the level of support that can be provided by endotracheal intubation, or when a patient cannot tolerate an endotracheal tube
...
Code 31603 is assigned for an emergency transtracheal tracheostomy, and 31605 is assigned for an emergency cricothyroid membrane tracheostomy
...
These codes represent two different approaches to establishing an airway
...
Fig
...
20-12 illustrates the transverse (across) incision used in a transtracheal approach
...
it is made between the cricoid cartilage and the sternal notch
...
Fig
...
20-13 illustrates entry into the trachea using the transtracheal approach
...
Fig
...
20-14 illustrates the vertical incision made for a cricothyroid tracheostomy
...
Fig
...
20-15 shows the entry into the trachea using the cricothyroid approach
...
Introduction
Codes in the Introduction category (31717-31730) report services of catheterization, nasotracheal and tracheobronchial aspirations, and transtracheal introduction of dilators, stents, or tubes for oxygen therapy
...
For an endotracheal intubation, assign 31500 (emergency endotracheal intubation) rather than a code from the Introduction category 31717-31730
...
For tracheal aspiration under direct vision, assign 31515 from the Endoscopy category
...
Code 31720 reports nasotracheal aspiration with a suction catheter for airway clearance
...
The procedure involves inserting a catheter into the nostril and through the trachea
...
A saline solution may be introduced to help remove blockage
...
Report 31725 if a fiberscope is used and the procedure is performed at the patient's bedside
...
Code 31725 includes moderate sedation
...
Excision/Repair
Excision/Repair procedures (31750-31830) in the Trachea and Bronchi subheading include plastic repairs, such as tracheoplasty and bronchoplasty, in addition to the excision of stenosis or of tumors, the suturing of tracheal wounds, scar revision and closure of a tracheostomy
Tracheoplasty involves the surgical repair of a damaged trachea
...
The repair may involve reconstruction of the trachea by the use of grafts or splints formed from cartilage taken from other areas of the body or by the use of prostheses
...
The codes are divided according to the approach used (cervical or thoracic) and the extent and type of repair
...
Bronchoplasty is repair of the bronchus and often involves the use of grafting repair or stents
...
A chest tube may be left in the area as a drain after the procedure and is not reported separately because it is bundled into the code to report the procedure
...
A grafting procedure is not bundled into the bronchoplasty code 31770 and is reported separately
...
LUNGS AND PLEURA
The Lungs and Pleura subheading (32035-32999) includes a wide range of codes to report procedures such as thoracentesis, thoracotomy, and pneumonostomy, in addition to lung transplants and plastic procedures
Incision
Thoracotomy involves making a surgical incision into the chest wall and opening the area to the view of the surgeon
This is a major surgical procedure during which the patient is under general anesthesia
...
The codes are divided according to the reason for the procedure, such as biopsy, control of bleeding, cyst removal, foreign body removal, or cardiac massage
...
The insertion of a chest tube is bundled into the thoracotomy codes
...
Excision
The Excision category contains codes for pleurectomy, biopsy, pneumonocentesis, removal, and reconstructive lung procedures
Pleurectomy is a procedure in which the physician opens the chest cavity to full view
...
With the chest open and the ribs spread apart by a rib spreader, the parietal pleura is removed
...
The parietal pleura lines the mediastinum and body walls as illustrated in Fig
...
20-16
...
If a pleurectomy is performed as part of another, more major procedure such as the removal of a lung (pneumonectomy), you would not report the pleurectomy separately
...
Note that after code 32310, pleurectomy, parietal "separate procedure" warns you not to report a pleurectomy if the pleurectomy was performed as a part of a more major procedure
...
Percutaneous needle lung or mediastinum biopsy is often performed under radiologic guidance so that correct placement of the needle can be ensured
...
As with the bronchography procedure described earlier, in the discussion of the Trachea and Bronchi subheading, if radiologic guidance was used, you report the service with a code from the Radiology section
...
There is a note following code 32405 (biopsy) that directs you to the Surgery section, General subsection, code 10022, when a fine-needle aspiration is performed, which differs from a tissue biopsy
...
A fine-needle aspiration is a procedure in which fluid is withdrawn for examination
...
Removal
Pneumonocentesis is the withdrawal of fluid from the lung by means of an aspirating needle
Air or gas in the pleural cavity is known as pneumothorax and occurs when the lung is traumatically ruptured or an emphysematous bulla ruptures
...
When the thoracic cavity (intrathoracic) air pressure increases, the pressure on the lung can result in collapse of the lung
...
The surgeon withdraws the air to allow the lung to reinflate
...
The codes for the removal of the lung are based on how much of the lung is removed—segmentectomy for one segment, lobectomy for one lobe, bilobectomy for two lobes, total pneumonectomy for an entire lung—as well as on the extent of the procedure and the approach
...
CODING SHOT
If a part of the bronchus was removed or repaired at the same time as the lobectomy or segmentectomy, report the service with add- on code 32501
...
The preferred method of accomplishing a thoracentesis is by having the patient sit with arms supported, as illustrated in Fig
...
20-17
...
local anesthesia is administered, a needle is inserted (Fig
...
20-18) between the ribs, and fluid is withdrawn
...
Thoracentesis is performed to withdraw fluid from the pleural space that has accumulated as a result of a variety of conditions, such as congestive heart failure, pneumonia, tuberculosis, or carcinoma
...
Thoracentesis may also be performed to insert a chest tube as an indwelling method of draining the accumulated fluid in the pleural space (pleural effusion), as illustrated in Fig
...
20-19
...
Local anesthesia is administered, and a small incision is made through the skin, fat, and muscle
...
The hole is then enlarged by using an instrument, and the tube is inserted into the pleural space
...
A suture is placed through the skin and tied to the tube
...
The tube is then secured with tape
...
The fluid is withdrawn by means of a suction device called a multichamber water-seal suction tube
...
This therapeutic procedure may be performed when the patient's pleural space contains air or gas (pneumothorax), blood (hemothorax), or a large amount of fluid (pleural effusion)
...
These conditions can be due to trauma, secondary to another disease process, or occur spontaneously
...
Surgical Collapse Therapy
...
Thoracoplasty

Thoracoplasty is a procedure in which a portion of the internal skeletal support is removed to treat a condition in which pus chronically collects in the chest cavity (chronic thoracic empyema)
...
The procedure is major and requires extensive resecting of the membrane that lines the chest cavity
...
Gauze is left in the cavity and after several days is removed
...
Note that code 32905, thoracoplasty, refers to "all stages
...
" The subsequent stages are for the removal of the packing and are bundled into the surgical code
...
Pneumonolysis is a procedure that is performed to separate the inside of the chest cavity from the lung to permit the lung to collapse
...
This procedure was originally used as a treatment for tuberculosis but is now used in the evaluation of pleural diseases, debridement of chronic emphysema, and as a treatment for emphysematous blebs, in addition to other therapeutic treatments
...
Pneumothorax injection (32960) is a therapeutic procedure in which the surgeon inserts a needle into the pleural cavity and injects air into the pleural cavity
...
The pressure in the thoracic cavity is increased and the lung partially collapses
...
This procedure is sometimes performed to treat tuberculosis
...
A chest tube may be inserted into the space for further injections of air
...
You would not report the insertion of the chest tube separately, as the insertion is bundled into the procedure code
...
STEP BY STEP BOOK I COMPLETED




INTRODUCTION TO CPT CODING
BOOK II

Section Objectives
Recognize the differences in the Respiratory subsection
Understand the Respiratory System guidelines
The Respiratory System subsection is divided into the following five anatomic sites (See Figures 4-46 and 4-47):

1
...
Nose
2
...
Accessory Sinuses
3
...
Larynx
4
...
Trachea and Bronchi
5
...
Lungs and Pleura
Consistent with other subsections of the CPT codebook, the Respiratory System also includes an Endoscopy subsection for each anatomic site where an endoscopic approach is applicable
...
It is important to note that surgical endoscopy always includes diagnostic endoscopy when performed by the same physician
...
FIGURE 4-46 Paranasal Sinuses

FIGURE 4-47 Respiratory System

Nose
Within each of the five anatomic sites, there are subsections that organize the codes further
...
For example, under the first anatomic site, Nose, the following subheadings are categorized by the type of procedure performed:

Incision
Excision
Introduction
Removal of Foreign Body
Repair
Destruction
Other Procedures

Codes 30130 and 30140 are unilateral, so if these procedures are performed bilaterally, the modifier 50 would be appended
...
Codes 30801 and 30802 are bilateral and would not have the modifier 50 appended
...
When selecting a code, look for the type of procedure performed under the correct anatomic site
...
For example, the treatment of inferior turbinate hypertrophy may be performed by excision (30130, 30140) or by destruction (30801, 30802)
...
These are in different subsections of the anatomic site of the nose
...
In other words, if only looking under the subheading Excision for the term inferior turnibate, coders would miss the other inferior turbinate codes for the nose listed under the Destruction subheading
...
These codes clarify widespread usage specific to inferior turbinates
...
Code 30130 describes excision of partial or complete inferior turbinate only, whereas code 30140 describes submucous resection of inferior turbinate
...
The excision or submucous resection of the superior and middle turbinate is reported with the unlisted code 30999
...
Codes 30801 and 30802 are reported for destruction procedures on the inferior turbinate mucosa via cautery and/or ablation
...
For cautery and ablation of superior or middle turbinates, report the unlisted code 30999 as well
...
1
...
When selecting the correct code for the nose, look for the __________________________, under the correct anatomic site
...
Code 30465 is reported for a bilateral procedure
...
If a unilateral procedure is performed, Modifier 52, Reduced Services, should be appended
...
(See Figure 4-48
...
)
Accessory Sinuses
Codes 31231-31297 are reported for nasal sinus endoscopy procedures
...
The physician uses a nasal/sinus endoscope to visualize the interior of the nasal cavity and the middle and superior meatus, the turbinates, and the spheno-ethmoid recess
...
The procedure may either be diagnostic (31231-31235) or surgical (31237-31297)
...
The documentation in the medical record should be carefully reviewed to determine the extent of the procedure before selecting the CPT code
...
FIGURE 4-48 Surgical Repair of Vestibular Stenosis


• Indirect laryngoscopy
• Direct laryngoscopy
• Flexible laryngoscopy

Sinus endoscopy codes 31233-31297 are used to report unilateral procedures, unless otherwise specified, and if performed bilaterally would be appended with the modifier 50
...
A separate code should not be assigned when diagnostic evaluation is performed on different areas
...
It is important to note that a surgical sinus endoscopy includes a sinusotomy (when appropriate) and diagnostic endoscopy
...
The codes 31231-31235 for diagnostic evaluation refer to employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the middle and superior meatus, the turbinates, and the spheno-ethmoid recess
...
Any time a diagnostic evaluation is performed, all of these areas would be inspected and a separate code would not be reported for each area
...
Codes 31295-31297 describe dilation of sinus ostia by displacement of tissue, any method, and include fluoroscopy if performed
...
(See Figure 4-49
...
)
Larynx
Codes 31505-31579 describe laryngoscopy procedures
...
These procedures allow the physician to visualize the larynx, or voice box, for any abnormalities
...
The laryngoscopy can be performed for diagnostic purposes (31505, 31520-31526, 31575, and 31579) or surgical/therapeutic purposes (31510-31515, 31527-31571, and 31576-31578)
...
When selecting the appropriate laryngoscopy code to report, it is also important to distinguish between the type of laryngoscope used (indirect, direct, or flexible)
...
Indirect laryngoscopy involves the use of a mirror to visualize the larynx (meaning the larynx is not directly visualized) or the use of a rigid telescope, if used indirectly
...
Indirect laryngoscopy is reported with codes 31505-31513
...
Direct laryngoscopy is performed with a lighted scope placed into the larynx to allow direct visualization of the larynx
...
Magnification may be performed with a telescope or by operating a microscope through this scope
...
Direct laryngoscopy is reported with codes 31515-31571
...
Laryngoscopy performed with a flexible fiberoptic laryngoscope is reported with codes in the 31575-31578 series
...
Whereas laryngeal stroboscopy, code 31579, may be performed with either a rigid or flexible laryngoscope
...
FIGURE 4-49 Sinus Endoscopy


Indirect laryngoscopy: A procedure in which a mirror is used to visualize the larynx or the use of a rigid telescope
...
Direct laryngoscopy: A procedure in which a lighted scope is placed into the larynx to allow direct visualization of the larynx
...
Magnification may be performed with a telescope or by operating a microscope through this scope
...
Flexible laryngoscopy: A procedure in which a flexible fiberoptic laryngoscope is used
...
Surgical laryngoscopy includes diagnostic laryngoscopy
...
Therefore, when both are performed, only the surgical laryngoscopy should be reported
...
Trachea and Bronchi
A bronchoscopy consists of a rigid or flexible bronchoscope being inserted through the oropharynx, vocal cords, and beyond the trachea into the right/left bronchi
...
Bronchoscopies are reported with codes in the 31622-31656 series
...
Bronchoscopy is considered an inherently bilateral procedure, and would not be appended with the modifier 50
...
All of the codes in the 31622-31656 series include fluoroscopic guidance during the procedure
...
Therefore, a separate code would not be reported for fluoroscopy in conjunction with bronchoscopy
...
Different codes are available to describe various procedures performed using bronchoscopy
...
These include the following three distinctly different types of biopsies:

1
...
Bronchial mucosal biopsies (31625), which are taken by direct vision and can be reported only once, even if performed at different anatomic sites
...
2
...
Transbronchial lung biopsies (31628), which are lung biopsies taken peripherally with fluoroscopic guidance of the biopsy forceps and should be reported only once regardless of how many transbronchial lung biopsies are performed in a lobe
...
However, when the biopsies are taken from different lobes, this represents new procedures with independent risk factors including biopsy forceps location of the lesion, bleeding, pneumothorax, air embolism, etc
...
3
...
Transbronchial needle aspiration biopsies (31629), 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 than an open procedure for a surgical biopsy
...
It is important to note that bronchoscopy codes 31615-31629, 31634, 31635, and 31645-31656 include conscious sedation as an inherent component of the procedure, and therefore, conscious sedation would not be reported separately
...
These codes are identified in the CPT codebook with the conscious sedation symbol (⊙) and can be found in Appendix G of the CPT codebook
...
For additional information on Appendix G, please refer to Chapter 11
...
Add-on code 31632 is intended to describe performance of transbronchial lung biopsy in each additional lobe, and 31633 describes the needle aspiration biopsies in each additional lobe after the initial lobar needle aspiration procedure
...
While these add-on codes may be reported for each biopsy in a separate lobe, parenthetical instructions direct coders that it would be inappropriate to report multiple biopsies or aspirations within the same lobe, as codes 31632 and 31633 should be reported only once regardless of how many transbronchial needle aspiration lung biopsies are performed in a lobe
...
Some possible sites for a bronchoscopic biopsy include the upper airway, which extends from the vocal cords to the lobar bronchi
...
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
...
(See Figure 4-50
...
)

2
...
When performing numerous transbronchial needle aspiration lung biopsies in the same lobe, how many times may the add-on codes 31622 and 31633 be reported?
FIGURE 4-50 Bronchoscopy

Lungs and Pleura
Thoracentesis is a procedure where accumulated fluid or air is removed from the pleural space by puncturing space between the ribs and is reported with codes 32421 and 32422
...
Code 32422 represents a component procedure of the larger procedure and therefore should not be reported separately in addition to the chest wall codes (19260, 19271, and 19272) and apical tumor resection codes (32503 and 32504)
...
If imaging guidance is performed with thoracentesis codes, then it would be appropriate to report one of the Radiology codes for fluoroscopic guidance in addition (eg, 76942, 77002, 77012)
...
(See Figure 4-51
...
)
Lung Transplantation (32850-32856)
The Lung Transplantation guidelines describe the three distinct components of physician work involved in lung allotransplantation, which are cadaver donor pneumonectomy, backbench work, and recipient lung allotransplantation
...
1
...
Cadaver donor pneumonectomy(s), which include(s) harvesting the allograft and cold preservation of the allograft (perfusing with cold preservation solution and cold maintenance) (32850)
...
2
...
Backbench work:
a
...
Preparation of a cadaver donor single lung allograft prior to transplantation, including dissection of the allograft from surrounding soft tissues to prepare the pulmonary venous/atrial cuff, pulmonary artery, and bronchus unilaterally (32855)
...
b
...
Preparation of a cadaver donor double lung allograft prior to transplantation, including dissection of the allograft from surrounding soft tissues to prepare the pulmonary venous/atrial cuff, pulmonary artery, and bronchus bilaterally (32856)
...
3
...
Recipient lung allotransplantation, which includes transplantation of a single or double lung allograft and care of the recipient (32851-32854)
...
Code 32855 is reported for a unilateral procedure, so if performed bilaterally, modifier 50 would be appended to it
...
Code 32856 is reported for a bilateral procedure, and would not require the appending of modifier 50
...
FIGURE 4-51 Thoracentesis

Code 32850 does not include the preparation and maintenance of cadaver allograft, as this work is separately reportable with the two new backbench preparation codes (32855, 32856)
...
The parenthetical note following bilateral backbench code 32856 instructs that for repair or resection procedures on the donor lung, use codes 32491, 32500, 35216, or 35276
...
1
...
type of procedure performed
2
...
Add-on codes 31632 and 31633 should be reported only once regardless of how many transbronchial needle aspiration lung biopsies are performed in a lobe
...
Respiratory System Exercises
Check your answers in Appendix B
...
True or False
1
...
Surgical sinus endoscopy does not include sinusotomy and diagnostic endoscopy
...
True or False
2
...
When diagnostic endoscopy code 31231 is performed bilaterally, it is appended with the modifier 50
...
True or False
3
...
Trachea and Bronchi Endoscopy codes 31615-31629 may be reported with the anesthesia codes for conscious sedation
...
True or False
4
...
If a backbench preparation procedure for lung transplantation is performed unilaterally, code 32856 may be reported with the modifier 52, Reduced services
...
True or False
...
Explain why
...
Short Answer
5
...
When surgical endoscopy code 31237 is performed bilaterally, how is it reported?
6
...
When performing direct diagnostic larynoscopy, would code 31505 be reported? Indicate either yes or no and why
...
Choose the Correct Code for the Following Procedure Report
7
...
History: A 68-year-old female had peripheral alveolar infiltrates in the right lower lobes that had been unchanged for six weeks
...
Procedure: Once the patient was properly sedated and locally anesthetized, the oxygen was turned up to 5 L/min
...
A fiberoptic bronchoscope was inserted through the nostril, visualizing the upper airways to the vocal cords
...
The vocal cords were visualized and observed for function
...
The bronchoscope was advanced into the trachea, and all the airways were inspected
...
Forceps were advanced through the suction channel of the bronchoscope into the right lower-lobe bronchus, leading to the infiltrate
...
A fluoroscope was activated, and the biopsy forceps were advanced into the infiltrate, then backed off by 1 to 2 cm
...
Under fluoroscopic guidance, the forceps were opened, a transbronchial biopsy was obtained on expiration, and the forceps were removed
...
Three to six biopsies were obtained in one lobe with fluoroscopic guidance
...
The bronchoscope was withdrawn from the airways, care fully visualizing the trachea, and then withdrawn from the patient
...
The chest was inspected for a pneumothorax with the fluoroscope
...
The biopsies were placed in formalin and sent to pathology
...
How is this procedure reported?
8
...
History: A 50-year-old female with Stage IV (metastatic) adenocarcinoma of the left lower lobe developed shortness of breath and left lower lobe atelectasis from progressive endobronchial tumor growth seen on serial CT scans
...
At bronchoscopy, following dilation a stent was placed in the left lower lobe bronchus
...
Procedure: A rigid bronchoscope was advanced to the stenotic area
...
A dilation catheter was placed through the bronchoscope into the small opening in the tumor mass and was threaded distally to just beyond the tumor mass under fluoroscopy
...
The dilating catheter was removed, and a guidewire was inserted through the bronchoscope into the now patent trachea
...
The bronchoscope was removed, leaving the guidewire in place, and the stent catheter was manipulated over the guidewire into the previously stenotic area
...
The bronchoscope was again inserted, and the area was visualized both through the bronchoscope and by fluoroscopy
...
Two metal markers were taped to the external chest wall under fluoroscopy
...
The stent was then deployed using both the markers for fluoroscopic guides and under direct vision by the physician using the bronchoscope
...
How is this procedure reported?

BOOK II COMPLETED

PRINCIPLES OF CPT CODING
BOOK III
Respiratory System
The Respiratory System subsection of the CPT code set contains codes for reporting procedures of the following anatomic subheadings:
Nose
Accessory sinuses
Larynx
Trachea and bronchi
Lungs and pleura

FIGURE 4-26
Respiratory System
Figure 4-26 highlights the various parts of the respiratory system
This section includes a review of some of the basic guidelines associated with reporting the nasal endoscopy, laryngoscopy, bronchoscopy, and thoracoscopy codes
...
Sinus Surgery
Four separate sinus cavities exist on each side of the face (see Figure 4-27
...
The maxillary sinus (also called the maxillary antrum) is below the eye, the ethmoid sinus is between the eye and the nose or nasal cavity, the sphenoid sinus is behind the nasal cavity, and the frontal sinus is above the eye in the forehead region
...
Because these sinuses are in separate anatomic locations, there is a separate and significant amount of work involved with each sinus surgery
...
Surgery on the sinuses can be performed through an incision on the face or forehead
...
This type of sinus surgery is reported with the codes in the 31000-31230 series
...
FIGURE 4-27
Paranasal Sinuses

FIGURE 4-28
Paranasal Sinuses: 31231-31297

The physician or other qualified health care professional uses an endoscope for visualizing and magnifying the internal structure of the sinuses
Nasal Endoscopy
Surgery on the sinuses can also be performed through the nose by means of a fiberoptic telescope or endoscope
...
Codes 31231-31297 are used for endoscopic sinus surgery
...
Separate codes are available for reporting diagnostic nasal/sinus endoscopy and surgical nasal/sinus endoscopy
...
Codes 31231-31297 are used to report unilateral procedures unless otherwise specified in the code descriptor
...
If one of the procedures listed in this range of codes is performed bilaterally and the code descriptor does not specify bilateral procedure, modifier 50, Bilateral procedure, is appended to the appropriate code
...
Codes 31231-31235 for diagnostic nasal/sinus endoscopy refer to the use of a nasal/sinus endoscope (see Figure 4-28) to inspect the following:
The interior of the nasal cavity
The middle and superior meatus
The turbinates
The sphenoethmoid recess
Whenever a diagnostic evaluation is performed, typically all of the areas listed in Figure 4-28 would be inspected
...
A separate code is not reported for each area inspected
...
Codes 31237-31297 are used to report surgical nasal/sinus endoscopy
...
A surgical sinus endoscopy includes a sinusotomy, when appropriate, and diagnostic endoscopy
...
When surgical and diagnostic endoscopies are performed at the same session, only the surgical endoscopy is reported, because the diagnostic procedure is considered an integral part of any therapeutic procedure
...
Codes 31256-31288 represent procedures that are performed for removal of soft tissue and/or bone to surgically enlarge sinus ostia or create openings from the sinuses into the nose, nasopharynx, or adjacent sinuses (eg, frontal into ethmoidectomy site)
...
Codes 31295-31297 are used for endoscopic dilation of the sinus ostia
...
Code 31295 is used when endoscopic dilation is performed on the maxillary sinus ostium either transnasally or via the canine fossa
...
Code 31296 is reported for endoscopic dilation of the frontal sinus ostium
...
Code 31297 is reported for endoscopic dilation of the sphenoid sinus ostium
...
Laryngoscopy
Codes 31505-31579 are used to report various laryngoscopic procedures
...
This range of codes includes both diagnostic and therapeutic procedures
...
When a diagnostic procedure is performed with a therapeutic laryngscopic procedure, only the therapeutic procedure is reported
...
The diagnostic procedure is considered an inclusive component of the therapeutic procedure
...
Operating Microscope (69990)
Many of the codes in this section include the use of an operating microscope (31526, 31531, 31536, 31541, 31545, 31546, 31561, and 31571) to perform microsurgical techniques, which are inclusive when these codes are reported
...
The parenthetical notes that appear after each of these codes or in the code descriptor indicate that code 69990 is not reported separately
...
Code 69990 is an add-on code, which means that it is reported for the use of an operating microscope in addition to the primary procedure code
...
This separate code is reported only when the use of the operating microscope is not considered an inclusive component of the procedure performed
...
Diagnostic Direct Laryngoscopy of Newborn (Use of Modifier 63)
Code 31520 is used to report diagnostic direct laryngoscopy of a newborn, with or without tracheoscopy
...
Performing this procedure on a newborn requires additional skill and time
...
Unless otherwise designated, modifier 63, Procedure performed on infants, may be appended to most codes to indicate that the procedures performed on neonates and infants up to a present body weight of 4 kg have resulted in significantly increased complexity and work
...
However, the parenthetical note following code 31520 advises users not to append modifier 63 to this code, because the code already reflects the increased complexity associated with this type of patient
...
Approach Techniques—Indirect and Direct
There are separate codes to report indirect and direct laryngoscopy
...
Indirect laryngoscopy, reported with codes 31505-31513, involves the use of a mirror to visualize the larynx (ie, the larynx is not directly visualized)
...
Direct laryngoscopy, reported with codes 31515-31571, is performed with a lighted scope to allow direct visualization of the larynx
...
Flexible Fiberoptic Laryngoscopy
Laryngoscopy performed with a flexible fiberoptic laryngoscope is reported with the codes in the 31575-31578 series
...
Diagnostic laryngoscopy, biopsy, removal of foreign body, and removal of a lesion are reported using these codes
...
If laryngoscopy is performed with the patient under general anesthesia, then it would be appropriate to append modifier 23, Unusual anesthesia
...
Occasionally, because of unusual circumstances, a procedure that usually requires either no anesthesia or local anesthesia may be performed under general anesthesia
...
This circumstance is reported by appending modifier 23 to the procedure code of the basic service
...
For example, if a diagnostic direct laryngoscopy with tracheoscopy is performed on a 3-year-old child under general anesthesia, code 31523-25 is reported
...
CODING TIP The 31575-31578 series is not used to report the evaluation of swallowing and/or laryngeal sensory testing as part of a flexible fiberoptic endoscopic evaluation
...
Use codes 92612-92617 to report those services
...
FIGURE 4-29
Bronchoscopy: 31622-31651
Bronchoscopy
Bronchoscopy is reported with the codes in the 31622-31651 series (see Figure 4-29)
A number of different codes are available for reporting various procedures performed via bronchoscopy
...
If more than one bronchoscopic procedure is performed, it is appropriate to report these procedures separately
...
It is important to note that all the codes in the 31622-31651 series include fluoroscopic guidance
...
Therefore, it would not be appropriate to separately report fluoroscopic guidance when performed in conjunction with the 31622-31651 bronchoscopy codes
...
Code 31622 is used to report diagnostic bronchoscopy
...
This code is reported for a procedure that involves the use of a bronchoscope with visualization of all major lobar and segmental bronchi
...
It may also include obtaining diagnostic washings as part of the examination
...
CODING TIP Bronchoscopy is considered an inherently bilateral procedure
...
Code 31622 is designated as a separate procedure
...
Diagnostic bronchoscopy is not separately reported when performed as an integral component of another procedure or service
...
Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same physician or other qualified health care professional
...
(Refer to the Surgery Guidelines section of this chapter for a discussion of the separate procedure designation)
...
The following clinical vignette is provided as an example of the appropriate use of code 31622:
31622
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed
diagnostic, with cell washing, when performed (separate procedure)
EXAMPLE
A 72-year-old man undergoes a diagnostic fiberoptic bronchoscopy for evaluation of hemoptysis
...
His chest X ray is normal
...
The physician or other qualified health care professional inserts the bronchoscope through the upper airway, noting any abnormalities
...
The vocal cords are visualized, and the structure and function are noted
...
The bronchoscope is advanced into the tracheobronchial tree
...
The patient has mild erythema throughout the tracheobronchial tree
...
In the right lower lobe, blood is seen coming from the right posterior basilar segment
...
Sterile saline washings of this bronchus are obtained and sent for culture and cytologic examination
...
Code 31623 is used to report bronchoscopy with brushings or protected brushings
...
Brushings or protected brushings take significantly more time to perform than bronchoscopy with bronchial washing
...
Protected brushings involve passing a catheter through the bronchoscope into an area of diseased lung, sometimes with the use of fluoroscopic guidance
...
When performed, the fluoroscopic guidance is included in reporting code 31623
...
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 cytologic and microscopic examinations
...
Several passes of the unprotected brush may be required and are included in the procedure
...
Code 31624 is used to report bronchoscopy with bronchial alveolar lavage
...
Bronchial alveolar lavage allows the recovery of cells as well as noncellular components from the epithelial surface of the lower respiratory tract
...
This differs significantly from "washings," which refer only to the aspiration of secretions or small amounts of instilled saline from larger airways
...
Bronchial alveolar lavage involves repeated instillations of aliquots of sterile saline into a segment of lung with aspiration into one or more containers
...
Sequential and separate aspirations are numbered for laboratory testing
...
Within the bronchoscopy code family, there are 3 distinct types of biopsies that are performed via bronchoscopy
...
They are as follows:
Bronchial mucosal
Transbronchial lung
Transbronchial needle aspiration
Bronchial or endobronchial biopsies, reported with code 31625, are obtained by biopsying the lesion under direct vision and can be reported one time only, even if performed at different anatomic sites
...
Code 31626 is a stand-alone code that is used to report bronchoscopy with placement of fiducial markers (eg, gold or dye markers) to mark the tumor's position
...
Bronchoscopic placement of one or more fiducial markers is usually performed in conjunction with navigational bronchoscopic procedures
...
Code 31627 is used to report bronchoscopy with computer-assisted, image-guided navigation (also called navigational bronchoscopy)
...
Navigational bronchoscopy enables an individual to manever through multiple branches of the bronchial tree to reach targeted lesions of the lung
...
Code 31627 is an add-on code that can be used in conjunction with other bronchoscopic procedures
...
CODING TIP Three-dimensional (3D) reconstruction, which enables virtual bronchoscopy from the patient's computerized tomography (CT) and is used to map the pathway to the lesion, is included in code 31267
...
Transbronchial lung biopsies, reported with code 31628, are taken peripherally with fluoroscopic guidance of the biopsy forceps
...
It is important to note that when the transbronchial lung biopsies are taken from different lobes, they represent procedures with independent risk factors such as bleeding, pneumothorax, or air embolism
...
Add-on code 31632 is reported in conjunction with code 31628 for the performance of a transbronchial lung biopsy performed in each additional lobe
...
A critical element to the appropriate application of these codes is that, while add-on code 31632 may be reported for each biopsy performed in a separate lobe, it would not be appropriate to report multiple biopsies within the same lobe
...
The third type of biopsy performed via bronchoscopy is transbronchial needle aspiration (TBNA)
...
Reported with code 31629, TBNA biopsies 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 that otherwise would require an invasive surgical approach with the additional potential risks of an open approach procedure
...
Add-on code 31633 is reported in conjunction with code 31629 for the performance of a needle aspiration biopsy performed in each additional lobe after the initial lobar needle aspiration procedure
...
As stated previously, a critical element to the appropriate application of these codes is that, while add-on code 31633 may be reported for each aspiration biopsy performed in a separate lobe, it would not be appropriate to report multiple biopsies in the upper airway or within the same lobe
...
The possible sites for a bronchoscopic biopsy include the upper airway, which extends from the vocal cords to the lobar bronchi, and each of the 5 lobes of the lungs and their bronchi: the right upper, middle, and lower lobes and the left upper and lower lobes
...
Code 31643 is used to report bronchoscopy with placement of catheter(s) for intracavitary radioelement application for clinical brachytherapy
...
This code includes only the bronchoscopy and placement of catheter(s)
...
It does not include the clinical brachytherapy portion of the procedure
...
When performed, intracavitary radioelement application is reported separately with the appropriate code from the 77761-77763 series
...
Remote afterloading high-intensity brachytherapy is also reported separately with the appropriate code from the 77785-77787 series
...
(Refer to Chapter 5 for further discussion of brachytherapy
...
)

FIGURE 4-30
Thoracoscopy: 32601-32674
Codes 31647, 31648, 31649, and 31651 report bronchoscopy services for bronchial valves
Code 31647 is used to report airway sizing and insertion of bronchial valve(s) for the initial lobe treated
...
Add-on code 31651 is used to report airway sizing, and insertion of bronchial valve(s) for each additional lobe treated, when performed in conjunction with code 31647
...
Code 31648 is used to report removal of one or more bronchial valves from a lobe in the lung, and add-on code 31649 is reported with removal of bronchial valve(s) from each additional lobe treated, when performed in conjunction with code 31648
...
Computed tomography has now replaced most bronchography procedures
...
Code 31899, Unlisted procedure, trachea, bronchi is reported when bronchography is performed
...
Thoracoscopy
Thoracoscopy is reported with codes in the 32601-32674 series
...
A separate series of codes report diagnostic thoracoscopy (32601-32609) and surgical thoracoscopy (32650-32674)
...
Thoracoscopy is the direct examination of the pleural cavity using an endoscope (see Figure 4-30)
...
To insert the thoracoscope into the pleural cavity, pneumothorax must first be completed
...
This pneumothorax is included in the thoracoscopy code reported
...
Examination of the pleural cavity is possible only if the pleural space between the lung and chest wall is large enough to manipulate the instruments easily and to visualize all important areas of the thoracic cavity
...
Depending on the location of the pleural lesion, the point of entry of the scope may vary for the affected area to be viewed, biopsied, or treated
...
Diagnostic thoracoscopy involves examination and biopsy only
...
Surgical thoracoscopy, in addition to examination and possible biopsy, always includes a therapeutic operative procedure
...
Surgical thoracoscopy always includes diagnostic thoracoscopy
...
For example, thoracoscopic examination, biopsy, and decortication are all included when code 32651 is reported
...
If more than one thoracoscopic procedure is performed during the surgical thoracoscopy, all procedures are reported separately
...
The primary procedure is reported without a modifier
...
Modifier 51 is appended to the secondary procedure(s) performed
...
Modifier 51 is used to report multiple procedures (other than E/M services) performed at the same session by the same provider
...
(Refer to Chapter 8 for further discussion of modifiers
...
)
If the thoracoscopic procedure that was performed is not specifically listed in the 32601-32674 series of codes, the unlisted procedure code 32999 is used
...
When an unlisted code is used, it may be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time, effort, and equipment necessary to provide the service
...
(Refer to Chapters 1 and 5 for an expanded discussion regarding unlisted codes
...
)
Pneumonectomy
Codes for excision of a lung (pneumonectomy) are in the 32440-32491 series
...
Pneumonectomy is reported with the codes in the 32440-32445 series
...
Removal of the lung involving other than pneumonectomy is reported with codes in the 32480-32491 series
...
A pneumonectomy, reported using code 32440, is removal of the entire lung
...
Code 32442 is used to report a sleeve pneumonectomy
...
A sleeve pneumonectomy involves a pneumonectomy and also includes resection of the tracheal carina with end-to-end anastomosis of the trachea and contralateral (opposite side) mainstem bronchus
...
Extrapleural pneumonectomy, reported using code 32445, includes resection of the parietal pleura, which is the thoracic lining of the ribs, diaphragm, and mediastinum
...
CODING TIP If lung resection is performed with chest wall tumor resection, report the appropriate chest wall tumor (19260-19272) in addition to lung resection (32440-32445)
...
A lobectomy is the removal of a single lobe of the lung
...
Code 32480 reports a single lobetomy
...
This code is used for either the removal of one of the three lobes in the right lung (right upper lobe, right middle lobe, or right lower lobe) or removal of one of two lobes in the left lung (left upper lobe, left lower lobe)
...
A bilobectomy, reported with code 32482, is removal of two lobes of the right lung (eg, right upper and right middle or right middle and right lower)
...
A bilobectomy is not removal of one lobe from the right lung and one lobe from the left lung
...
Bilobectomy is not a bilateral procedure
...
Bilobectomy is not performed on the left lung, because there are only two lobes on the left side
...
When both lobes of the left lung are removed, this operation is a pneumonectomy
...
Each lobe of the lung has multiple segments
...
A segmentectomy, reported using code 32484, is removal of one of the divisions of a lobe
...
Code 32486 is used to report a sleeve lobectomy
...
A sleeve lobectomy is similar to a lobectomy but also includes removal of a portion of the bronchus going to the remaining lung
...
Most commonly, sleeve lobectomies are upper lobectomies that include removal of the upper lobe plus a portion of the bronchus going to the lower lobe(s)
...
Completion pneumonectomy is reported with code 32488
...
A completion pneumonectomy is a secondary operation in which the lung tissue remaining after previous lung excision surgery is entirely removed
...
For example, a portion of a right lung (eg, a lobe) has been removed previously for a cancerous tumor
...
The cancer recurs, and it is necessary to remove all the remaining right lung tissue
...
This subsequent removal of the remaining lung tissue on the right lung is a completion pneumonectomy
...
Code 32491 is used for the excision of bullous or nonbullous emphysematous lung(s) for lung volume reduction
...
This code is specifically for procedures performed on patients with severe emphysema who are undergoing the procedure to reduce lung volume
...
Although this is generally a bilateral procedure, the word lung(s) in the code descriptor indicates that this procedure can be performed unilaterally
...
Therefore, code 32491 reflects both unilateral and bilateral procedures
...
Code 32501 is an add-on code used to report resection and repair of a portion of the bronchus when performed at the time of a lobectomy or segmentectomy
...
This code is used when a portion of the bronchus to the preserved lung is removed
...
A plastic closure is required to allow functional preservation and is not to be used for closure for the proximal end of a resected bronchus
...
Code 32501 is never to be reported as a stand-alone code
...
This code is reported in conjunction with codes 32480, 32482, and 32484
...
(Refer to the Surgery Guidelines section of this chapter for a discussion of CPT add-on codes)
...
Introduction and Removal
Code 32550 is used to report insertion of a tunelled catheter into the pleural space for drainage and management of pleural effusions such as noninfected benign pleural effusion, recurrent pleural effusion of unknown etiology, and trapped lung with pleural effusion
...
Code 32550 does not include the incisions and dissection required to remove the catheter and cuff
...
Code 32550 is not reported in conjunction with thoracentesis codes 32554 and 32555
...
Code 32551 is used for the introduction of a tube thoracostomy, which includes connection to a drainage system such as a water seal, if performed
...
Code 32552 is used for the removal of an indwelling tunnelled pleural catheter with a cuff
...
Code 32553 is used for the placement of percutaneous, intra-thoracic interstitial devices, such as fiducial markers or dosimeters that are placed for radiation therapy guidance
...
Code 32553 is reported only once, and the supply of the interstitial device(s) is separately reported
...
Code 32554 is used to report thoracentesis by needle or catheter, for aspiration of the pleural space without imaging guidance, and code 32555 is reported for the procedure when imaging guidance is performed
...
Codes 32551, 32554, and 32555 should not be reported in conjunction with lung tumor resection codes 32503 and 32504
...
Code 32556 is used to report percutaneous pleural drainage with the insertion of an indwelling catheter without imaging guidance, and code 32557 is used for the procedure with imaging guidance
...
Codes 32554-32557 should not be reported in conjunction with the catheter insertion code 32550, tube thoracostomy code 32551, or the imaging guidance codes 76942, 77002, 77012, 77021 and 75989
Destruction
Codes 32560-32562 report procedures for the management of pleural effusions
...
Code 32560 is used for instillation of an agent (eg, talc) to achieve pleurodesis
...
Code 32561 is used for instillation of an agent to perform fibrinolysis in order to breakup multilocated pleural effusion
...
Code 32562 reports instillation of an agent for fibrinolysis performed on a subsequent day
...
Although instillation of a fibrinolytic agent may be performed multiple times per day over the course of several days, code 32561 is reported only once on the initial day of treatment
...
Code 32562 is also reported only once on each subsequent day of treatment
...
Video-Assisted Thoracic Surgery (VATS)
When pleural cavity or lung biopsy procedures are enhanced with video-assisted techniques, the procedure is called video-assisted thoracic surgery (VATS)
...
These procedures are reported with codes in the 32601-32674 series
...
VATS requires additional incisions for the introduction of retractors and instruments used for exposure and dissection of lesions
...
VATS expands the intrathoracic image of conventional thoracoscopy (which is limited to the surgeon and restricted by the keyhole view from the thoracoscope) to multiple viewers
...
VATS allows the image obtained via the thoracoscope to be seen by multiple viewers by continuous video image display on a monitor in the surgical suite
...
VATS procedures can involve the removal of tissue for diagnosis
...
the removal of blebs, bullae, cysts, tumors, or lesions
...
the removal of portions of the lung or the entire lung
...
and even the removal of adjacent structures
...
Various techniques may be used (eg, incisional resection, cautery resection, stapled wedge)
...
Codes 32607, 32608, and 32609 are used for thoracoscopic (VATS) biopsy procedures
...
Code 32607 is used for diagnostic biopsy of lung infiltrates, code 32608 is used for diagnostic biopsy of lung nodules or masses, and code 32609 is used for thoracoscopic biopsy of the pleura
...
Codes 32607 and 32608 may only be reported once per lung and cannot be reported when more extensive surgical procedures are performed
...
Codes 32666-32668 are used to report thoracoscopic excision of the lung
...
Each procedure involves a certain level of removal according to the type and amount of tissue that is being excised
...
Code 32666 is used for an initial therapeutic wedge resection using VATS
...
Modifier 50 is appended to bilateral procedures
...
This code is restricted from being used in conjunction with codes 32440, 32442, 32445, 32488, and 32671
...
Code 32667 is an add-on code used to report additional thoracoscopic therapeutic wedge resections
...
This code is used with code 32666 and cannot be reported when more extensive surgical procedures are performed
...
Code 32668 is an add-on code used to report diagnostic wedge resection that is followed by anatomic lung resection
...
A parenthetical note in the CPT code set lists the primary procedures that may be used in conjunction with code 32668
...
Codes 32669-32674 are used to report VATS resection and removal procedures that vary according to the amount of tissue removed, the type of tissue removed, or in the difficulty of removal
...
Instructions provided to users include the appropriate codes to use for open thymectomy
...
the appropriate codes to use for open excision of mediastinal cyst or tumors
...
the codes that are used for exploratory thoracoscopy (including exploration that includes biopsy)
...
the codes that are reported for mediastinal and regional lymphadenectomy performed via thoracotomy
...
and the codes that may be reported in conjunction with add-on code 32674
...
Stereotactic Radiation Therapy
Thoracic stereotactic body radiation therapy (SRS/ SBRT) utilizes externally generated ionizing radiation to inactivate or eradicate a defined target(s) in the body without the need to make an incision
...
The target is defined by and the treatment is delivered using high-resolution stereotactic imaging
...
Treatment and planning is a collaboration between a surgeon and radiation oncologist
...
The surgeon identifies and delineates the target for therapy
...
The radiation oncologist reports the appropriate code(s) for clinical treatment planning, physics and dosimetry, treatment delivery and management from the Radiation Oncology section (Refer to 77295, 77331, 77370, 77373, 77435 in the CPT code set)
...
Target delineation involves specific determination of the tumor borders in order to identify tumor volume and its relationship with adjacent structures such as, the chest wall, intraparenchymal vasculature and atelectatic lung, as well as the presence of previously placed fiducial markers, if present
...
When a fiducial-less tracking system is utilized, target delineation includes availablity to identify and validate the thoracic target prior to treatment delivery
...
For placement of fiducial markers, see codes 31626, 32553
...
Code 32701 is used to report thoracic target(s) delineation for SRS/SBRT
...
When the treatment requires more than one treatment session, code 32701 is only reported once for the entire course of treatment
...
Radiation oncology codes 77261-77799 should not be reported with code 32701
...
CODING TIP When a diagnostic biopsy is performed, evaluated by a pathologist and during that same operative session the results are used to determine the extent of surgical resection, only the most extensive procedure performed is reported (eg, segmentectomy, VATS lobectomy)
...
Lung Allotransplantation
Solid organ transplantation has rapidly evolved since the first living donor kidney transplantation was performed in the United States in 1954
...
Despite the interest of living donors, a discrepancy still exists between the number of potential recipients and the number of donors, which has resulted in increasing the utility of organs from deceased donors, thereby widening the pool of transplant organs available today
...
Technological advancements and better surgical skills allow today's transplant surgeons to salvage organs that would have previously been discarded
...
The three distinct components of work involved with lung allotransplantation are as follows:
Cadaver donor pneumonectomy(s) (32850)
Backbench work (32855-32856)
Recipient lung allotransplantation (32851-32854)
The first component of the lung allotransplantation process is the cadaver donor pneumonectomy
...
This step involves preparation of the organ, including harvesting the allograft and cold preservation of the allograft (perfusing with cold preservation solution and cold maintenance), and is reported with procedure code 32850
...
It is important to note that the harvest of the lung allograft may be from either a cadaver or a living donor
...
However, when heart and heart-lung transplant combinations are performed, grafts may be harvested from cadaver donors only
...
The second component of work of the lung allotransplantation process is backbench work
...
This step involves standard preparation of a cadaver or living donor allograft prior to transplantation
...
Backbench work may include tailoring or reconstruction, ie, alteration of arteries and/or veins in order to render the allograft transplantable
...
Procedure codes 32855-32856 are used for standard backbench work (eg, the dissection and removal of surrounding soft tissues) and reconstruction work (eg, alteration of organs) and reflect the expertise involved in the effort to render the organs usable
...
The third and final component of work is allotransplantation, reported with codes 32851-32854, as appropriate
...
This step includes the appropriate organ removal (if required) prior to transplantation, transplantation of the allograft, and care of the recipient
...
If repair or resection work is required on the donor lung, see codes 32491, 32506, 32507, 35216, 35276
...
BOOK III COMPLETED
...