Transcript for:
Bronchoscopy CPT Coding Webinar

and I want to welcome everybody to today's topic scoping out the codes bronchoscopy CPT coding and I want to introduce Shay Lunt and she's a consultant for Hagen Consulting Group and she's got a wealth of experience just tons of experience in physician auditing physician billing coding and compliance she's doing a lot of audits right now as well as a lot of trainers a lot of provider training as well she currently lives on a family farm in south-central Kansas and I'm from Iowa so we've got the Midwest gals on this webinar and she has two little girls juniper and Clementine so very cute girls so anyway Shay I think we're ready to turn it over to you and let you kick us off today thanks Kathy I'm super excited to be here today and talk to everyone about bronchoscopy our agenda today a we are going to review CPT coding for bronchoscopy so if you're looking for pcs for bronchoscopy that's gonna be done by Christie and that'll be next week so again this is just gonna be CPT we're gonna cover some respiratory anatomy that'll help us with our codes and some of the code descriptors and we'll go into the different bronchoscopy procedures and what can be done through a bronchoscopy or with a bronchoscopy and look at the cpt guideline and then we'll wrap it up with looking at the NCCI edits and guidelines that pertain to endoscopy ZAR bronchoscopy procedures so again welcome everybody we're happy to start in today so we're gonna start with the anatomy part respiratory anatomy and again this is just gonna help us understand the bronchoscopy procedures that are performed and as well as those CPT code descriptions that mention various Anatomy parts as well um the respiratory system is divided into two main components we have the upper respiratory tract and the lower respiratory tract so here we are first looking at the upper respiratory tract so that's going to include the nose and the nostrils the nasal cavity the mouth the throat or the fair necks and then down to the larynx or the voice box all of these structures play a specific role in the respiratory system so when you breathe through your nose or mouth the air is filtered by those nasal hairs at the opening of your nostrils and then also the mucous membranes which line the entire respiratory system that inhaled air is moistened it's warmed and it's cleansed in the nasal cavity and then the fair knacks or the throat um connects the nasal and oral cavities to the lenox so the fair next that's where your tonsils and adenoids if you still have those those are there and then the lenox forms the entrance to the lower respiratory system so the Lenox is the end of the upper respiratory system and then we go into the down into the trachea and that's where we get down to the lower respiratory system um the epiglottis is located in the lair niché's and that prevents food or liquid from entering the lower respiratory tract and then the vocal cords are in the larynx and that what those are are just connective tissue bands that are stretched across the layer necks and they vibrate and that's what produces sound so that's the upper respiratory tract next we have pointer off sorry next we have the lower respiratory tract so that's kind of going down into the chest cavity and it's made up of the trachea the lungs and then all the segments of the bronchial tree which include the alveoli so all of these organs are located in the chest cavity so after that inhaled air moves through the layer necks it's going to go down into the trachea or the windpipe and then airflow from their branches off into two bronchi so you can see we have one bronchi going to or one bronchus leads to the left lung and then one to the right and then deeper into the lungs each of those bronchus divides into secondary and tertiary bronchi and then those continue to branch into smaller and smaller Airways getting down to the bronchioles so there's actually no cartilage in the bronchioles um and so they are really subject to constriction or an obstruction so if you think like during an asthma attack that's that's that constriction happening and the bronchioles those end in air sacs and those are called the a viola so you can see that in the picture here um right here these little air sacs and on the surface of those alveoli they're all bunched together there and on the surface of them there's a network of capillaries there and that's where the air exchange take place so the capillaries are network that are carrying the blood from the veins from other parts of the body and that's where the gas exchange takes place so the carbon dioxide from that blood is exchanged for oxygen from the a viola and then after that blood is oxygenated it goes to the heart where it's pumped out to the bodies so when you breathe out the carbon dioxide is exhaled and then it's expelled from the body so a lot of important functions happen happening there in those little alveolar sacs and these two pictures just show a little bit more anatomy and when you start reading these bronchoscopy reports you'll see some of these different segments mentioned and some of these different Anatomy parts mentioned so I thought I would include these just for your guys's reference the Carina is right there we're right in the middle you can see it's kind of the fork where the bronchus divides that you will always see almost always see in a bronchoscopy report as a Prinze point so that's what that's talking about and then you can see the different lobes we have two lobes on the left lung and then three lobes on the right lung and again you can see those different lobes over here some of the CPT codes are gonna reference lobes or additional lobes things like that so it's good to know where you're at as far as the anatomy goes and then the other part of the anatomy I wanted to point out here is the diaphragm so that is the muscle that's located below the lungs it's the major muscle of respiration it's dome-shaped so you can see that shape right here it contracts rhythmically and continually and most of the time it's involuntary so you're not thinking about it but upon inhalation the diaphragm contracts and it gets flat and then that's when the chest cavity enlarges this contraction it creates a vacuum which pulls that air into the lungs and then when you exhale the diaphragm relaxes and it returns to that dome-like shape and then the air is forced out of the lungs so the other important respiratory muscles are going to be the intercostal muscles those are the muscles between your ribs and then the abdominal muscles as well so I think that covers it for our anatomy and the actual bronchoscopy procedure itself this procedure is to look directly at the airway in the lungs so it uses a thin lighted tube and that's what's called the bronchoscope and it can be put in through the nose or the mouth and then it's moved down the throat in the windpipe or down through that trachea and into the airways so the healthcare provider that's doing that bronchoscopy they can see the voice box or that lenox they can see the the trachea they can see the large Airways those bronchus and then down into the lungs and the smaller branches even down into the bronchioles there's actually two different types of bronchoscope and you'll notice this in the code description it says rigid or flex and both types come in different widths or sizes the one that I think we see the most now is probably a flexible fiber-optic bronchoscopy and those can be performed on different different types of patients a rigid bronchoscopy is a straight tube so it's only used to view the larger Airways and some of the procedures that are done with the rigid bronchoscope mostly revolve involve removal so they can remove a large amount of blood or secretions they can use it to control bleeding they can use to remove foreign objects or diseased tissue or lesions and they can also use a rigid bronchoscopy to do some procedures such as like stents and other treatments and the flexible bronchoscope is more often used now unlike that rigid scope it can be moved down into the smaller Airways or those bronchioles and the flexible bronchoscope has many different uses and they can use it to place a breathing tube in the airway to help give oxygen they can use it to suction out secretions take tissue samples like a biopsy and they can even put medicine into the lungs through that bronchoscopy so it's very versatile in what they can do with it and that kind of leads into why we have so many different codes and so many different treatment options available when using a bronchoscopy so what are they used for we kind of touched a little bit on this but just to get further into it they are used to diagnose problems and then they're also used for procedures or treatment so the types of problems that are diagnosed with bronchoscopy include like tumors or different types of bronchial cancer airway blockage or narrowed obstructed Airways are looked at with bronchoscopy is often if there is in kind of inflammation or an infection like tuberculosis and yeah a fungal or a parasitic lung disease they'll often check it out with the bronchoscopy interstitial pulmonary disease if a patient has a persistent cough or is coughing up blood bronchoscopy are also used to look at that um there's also they also are used for follow-ups like if they see spots on a chest x-ray they can do a bronchoscopy to further see what's going on and if there's any vocal cord issues like vocal cord paralysis they can take a closer look with a bronchoscopy and then the treatments that are done and they can do a biopsy of tissue they can collect sputum they can put fluid into the lungs and then remove it to diagnose disorders and that's called a bronchial viola or lavage or B al and that's a pretty common procedure they can use bronchoscopy to remove secretions blood mucus plugs growths to clear Airways control bleeding remove foreign objects or any kind of other blockages they use it for laser therapy radiation treatment placement of small tubes or stents to keep an airway open and then they can also drain any areas of abscesses or pus so again many different uses of this bronchoscopy procedure which is why we have so many codes in this section so getting into the coding guidelines if you're following along in your CPT book the bronchoscopy codes start with code three one six two two and that's the code for the diagnostic procedure so that's kind of the base code for a lot of these codes we're going to talk about next from there that same base description remains but then after this in my colon you'll see the CPT code describe different diagnostic and surgical procedures performed by different texts and techniques using a bronchoscopy one guideline to keep in mind is that if a diagnostic bronchoscopy is performed at the same time as a surgical procedure you will not report that diagnostic procedure separately only that surgical bronchoscopy procedure another guideline to keep in mind is that fluoroscopy is bundled with almost all of the bronchoscopy codes so three one six two two all the way through three one six five one three one six six zero and three one six six one all include fluoroscopy so you won't be coding that separate also not included as moderate sedation and I think it used to be back when moderate sedation was included with certain codes but it's not now so if they do moderate sedation and you're billing for it it's documented and everything um you can report that separately if it's appropriate so jumping into the codes um like I said we'll start with three one six two two that's for the diagnostic bronchoscopy only it includes cell washing so bronchial washing you you might see abbreviated as BW or cell washing it involves injecting saline into the bronchial we're covering it immediately after each flesh and they so to do that they suck back on the syringe and then the cells that float back when they suction it with the Saline those are the cells that are analyzed and three one six two three is includes brushing or protected brushings and the brush it resembles a pipe cleaner and it's actually inserted through a tube in the bronchoscope and it's used to just gently wipe lung tissue or a lesion and then the cells that stick to that brush are taken to the lab and that's what they can study or analyze for a diagnosis on the next code I mentioned this on the previous slide but three one six two four is that bronchiole are lavage or be al that's similar to a bronchial wash but the lavage it requires just a larger volume of saline so it's it's normally done after a biopsy or a brushing just to increase the the cellular sample that's used for diagnosis of that infection or malignancy so the cell that float back out when section with the Saline those are the cells that are analyzed and then the next procedure is the bronchial or endo bronchial biopsy three one six two five so this is done after they visualized the bronchus they can take a sample of bronchial or endo bronchial tissue to study and then they can do more than one site at a time sometimes there's bleeding and they assess the bleeding control it and then they would remove the bronchoscope so a little bit more about the biopsy procedures there's a few more biopsy procedures that can be done with the bronchoscope we just talked about three one six two five but the bronchial or endo bronchial biopsy you might see that abbreviated as EB B for this one they can identify the lesion under direct vision and then the biopsy forceps go to that they can put the biopsy force forceps at that target site open the forceps position them at that lesion and then close them to get a sample for these types of biopsies it's important that they cut the sample rather than tear it and to preserve that cell structure and then they just take the forceps through that working channel in the bronchoscope out and they can look at those that cell or those cells in that biopsy to see what's going on the next type of biopsy is the trans bronchial biopsy or TB lb that one is three one six two eight four a single lobe and then three one six two three for each additional lobe this is when they obtain a sample through the bronchial wall they usually do this by using fluoroscopy so this is beyond direct vision they're using fluoroscopy and that helps guide the forceps down to the target area and then they use the forceps to get a biopsy again and and and this one is by lobe so that's different than the endo bronchial biopsy we just talked about if they do multiple biopsies in a single lobe you'll just use the three one six two one two eight code but if they're moving to additional lobes that's when you'll use that add-on code three one six three two and then the last biopsy code we have here is that needle aspiration so that's where they actually use a needle that's passed through the bronchoscope and through the bronchial wall and they obtain an aspiration biopsy so that's three one six to nine and there's an add-on code for each additional lobe again and that one's three one six three three so for those last two types of biopsies you'll just need to pay attention to where they're at as far as lobes go so you know whether you need to report that add-on code or not um just note that needle aspiration biopsy it's reported once four biopsies that are performed in the upper airway or in a lobe so if they do the needle aspiration biopsy is in that upper airway that's just reported one time okay so this brings us right oh sorry one more thing I wanted to mention these biopsy procedures are very important they are really used to accurately diagnose the specific type of cancer a lot of times for a patient and that really steers the treatment or the therapy that's used so for example small cell carcinoma is usually treated with specific chemotherapy and radiation because surgical resection is often not curative on the other hand if it's non small cell lung cancer like adeno carcinoma squamous cell and large cell types those they often do consist of surgical excision since chemotherapy is not usually effective so they can make highly individualized treatment plans that are designed for a patient's specific cancer type and they can only do that based on the information that's obtained from these biopsies so it really these biopsies are very valuable procedures in terms that have their he and treatment options okay so this brings us right into our first polling question Kathy thanks Shane so I just launched the poll so this is when we want to hear from you so what code is reported for bronchoscopy with three trans bronchial lung biopsies of a single lobe is it the first one at three one six two eight and three one six three two times two or is it just one code three one six to eight or is it C three one six two five times three so what do you think what code is reported for bronchoscopy with three trans bronchial lung biopsies of a single lobe and I can tell our audience is thinking about this initially we had some quick response now it's slowing down we've got about 50 percent of you out there who have voted so I really like to get like three-fourths or two-thirds of you because that way we can kind of gauge what you're what you're thinking as well as address any questions that might come out of this but I will tell you Shea I think we're gonna have some great discussion on this one so anybody else went away in what code is reported for bronchoscopy with three trans bronchial lung biopsies of a single lobe okay if not I'm gonna close the poll in three two one Shay we've got answers kind of we've got a clear majority so three one six two eight is the majority at 86 percent of our audience is saying that's the correct code however we do have a few people who are saying it is the first one and we have a smaller percentage who are saying it is the third choice sorry I still I'm um yeah great job guys the majority of you guys are right so for these codes if there's three biopsies in a single lobe you'll just have that single code since they're all in the single lobe if they were to go to different lobes that's when you get into adding that add-on code so great job okay the next code we're going to talk about is placement of fiducial markers this is a standalone code and what it it is for is a bronchoscopy procedure where they place fiducial markers the fiducial markers could be like gold or dye markers and the what it does is it directly marks the tumors position um so they know where that tumor is at when they're doing like radiation therapy and things like that they know where to target so the bronchus the placement of one or more fiducial markers it's usually performed in conjunction with the navigational bronchoscopic procedures so I'll talk about that in a little bit later there was actually a CPT assistant on this question they asked how to report gold markers gold markers are considered fiducial markers so you would use that three one six two six code and just some fun facts about this fiducial comes from a Latin word trustworthy since the marker can be relied upon to indicate that location of a tumor in order to aim the radiation therapy so if you think of the old dog named Fido or the US Marine motto semper fidelis and that those along the same lines and then gold is used because it's radiopaque and it shows well on the radiographs it's inert and it won't react with the body and it is also non-magnetic and therefore it's safe with MRIs so now you know and the next procedure is three one six or the next procedures for tracheal or bronchial dilation and it's reported with three one six three zero and this can be done with a rigid or a flexible bronchoscope depending on where that the dialect or the dilation needs to occur at the bronchoscope is advanced into the stenotic area and then they use a dilation catheter that's placed through the bronchoscope into that opening of where the stenosis is and then under fluoroscopy they thread it just beyond that focal stenosis to get that dilation get that to open up so here is a an example for this this patient was hospitalized and during the hospitalization had a tracheostomy tube the tracheostomy tube was removed five months ago but right where they had that tube in the mid trachea that's where they had some that patient has some focal stenosis so they used a rigid bronchoscope in this case they put it into that stenotic area and they used a dilation catheter that goes through the bronchoscope into the opening of where that stenosis is and they again put it distally beyond that focal stenosis and they were able to open it up so that's one like clinical example that you might see this procedure done for the next procedure is for trachea and bronchi stenting so there's two separate codes here it's for the trachea that one is 3 1 6 3 1 and then bronchial stents are reported with 3 1 6 3 6 for the initial bronchus and then there's an add-on code 3 1 6 3 7 for each additional major bronchus stented so those would be for the initial procedures done if they have to go back and do a revision of a tracheal or a bronchial stent that's reported with 3 1 6 3 8 and that would be if they did it in a separate session these procedures to get the stint where it needs to be they often use tracheal or bronchial dilation so these procedures in include that dilation the stents are they're also called tracheobronchial prosthesis and you can kind of you can see in my picture here this one is a tracheal stent up here and then this one's a bronchial stent so they just look like little tubes they're hollow in the middle and then they can be inserted into an airway um they can be used to treat a large variety of large airway diseases and prior to the development of the endo bronchial stent therapy chemotherapy and radiation were really the only way to reduce tumor size and open that obstructive airway so it's nice that they have more options to be able to treat these types of obstructions so again code three one six three six is for that first or the initial mainstem bronchus and then three one six thirty seven is an add-on code and that's reported when a second stent is placed in a different or a more distal bronchus and the three one six three eight is again that's only reported if they go back in and have to do an adjustment and stuff so that brings us right into our next polling question Kathy okay this is a true/false question bronchial dilation was performed for bronchial stunting do you report both codes three one six three zero and three one six three six is that true or false I'll read it to you again so it's a true false statement bronchial dilation was performed for bronchial stunting report both codes three one six three zero and three one six three six true or false ooh and we're gonna have some good discussion once again I always like that so anybody else went away in I've got a little bit more than fifty percent you I love when you pull if you've got a large group go ahead and pull them get the general consensus and then vote so anybody else want to weigh in if not I'm closing the poll in three two one so Shay we've got a pretty large majority at ninety five percent is saying this is a false statement but we've got one or two people who are saying it is a true statement though okay most of you guys are correct it's false that dilations gonna be included with those stenting codes so like I said oftentimes they're going to have to do dilation to get the sent in it's going to be included in that procedure it's inherent as part of those stenting codes so you will not report the stunting and dilation together all right so the next um topic we're going to cover is balloon occlusion I hope you guys are all enjoying enjoying our balloon animals we thought that was appropriate for our topic on an error in balloons and and different things so in this procedure for balloon occlusion this is used to treat a Blanc Bronco pleural fistula or BPF a BPF is often a post-op complication of thoracic surgery it can occur as a complication of a diseased lung or a previously normal lung as well but most often times we'll see it as a post-op complication what it is it's an abnormal passageway like a sinus tract that develops in between the large Airways in the lungs so those bronchus and then the space in between the membrane that line the lung so the pleural cavity so it's a very serious condition that they have to get treated right away so in this case they use fluoroscopy often times that that is this with the navigation of that bronchoscope tip to the area of the leak and then they can assess the leak then they'll use a balloon catheter to play that's placed at the side of the leak and then it's inflated until that week is occluded so then they'll keep that inflated catheter in the position and they'll use a sealant like fibrin that can be injected and then once that effective ceiling sealant is verified then the catheter and the bronchoscope are removed so that's how that procedure works and that's for balloon occlusion they'll first they'll assess the leak and then they can use the catheter to inflate that balloon catheter in place and appropriate sealant so there's a few steps there but that's how that procedure works the next procedure is foreign body removal this is a common one done with bronchoscopy the physician can actually use the bronchoscope to locate the foreign body in the airway sometimes there might have been you know some imaging done beforehand but they can't see it using the bronchoscope they can pass like a snare or a basket or a biceps forceps through a channel in the bronchoscope and then they'll use those to grasp the foreign body so you can see that in our picture here I don't know what it is maybe a button and then they can use that to remove the foreign body this can be done with or without fluoroscopic guidelines and then just to illustrate this is a very prevalent procedure airway foreign bodies occur 17,000 per year in the US and overwhelmingly it's in children under 3 years old I can relate to this because I have two kids that are 3 and under it and they put stuff in their mouths all the time so this is like my worst nightmare but 90% of aspirated foreign bodies are seeds or other organic material and actually half the time it's a peanut so um peanuts are actually dangerous because they absorb water and swell so a partial airway obstruction can turn into a complete obstruction so a lot of times these airway foreign body removal is truly an urgent procedure so I threw in some faq as we go here today this is our first one this was in CPG assistant I'm asking if it's appropriate to report the three one six two three which is the bronchoscopy with the brushing or the protective brushings three one six two five which is the biopsy code and then three one six three five which is removal of a foreign body so if they did all of three of those procedures together you can report them all they are not considered integral components of one another so it is it is appropriate to report all three of those together um the next procedure is for tumor removal or destruction so there's two separate codes here the first one three one six four zero is for excision of a tumor this can be done with or without fluoroscopic guidance they use a bronchoscope to actually grasp and excise the tumor and then in three one six four one they pass a laser or a freezing like a cryo probe through a channel in the bronchoscope and they use that to destroy the tumor or any areas of stenosis and then they remove the bronchoscope so if they use computer-assisted image-guided navigation you can report an add-on code which I'm going to talk about and that atom code is three one six to seven in addition to these codes and if they are doing photodynamic therapy from you can report that three one six four one code with the nine five 700 or nine or sorry nine six five seven over nine six five seven one and that's for the photodynamic therapy okay the next procedure is bronchoscopy with placement of a catheter for intra cavity radio element application so this is a pretty complex procedure but it is done for delivery of high-dose or eight gr brachytherapy treatment so what this code for code is for is for the bronchoscopic placement of the catheter which is then used for inter cavity radio element application or that high dose rate brachytherapy so the high dose rate brachytherapy it can be used in any anatomical site that's suited for brachytherapy it's performed with by using a remote after loading device that's called an after loader which that's what safely stores the radiation source between treatments and it's also what delivers the radioactive source directly to the patient during the therapy so there's a few steps to this the appropriate implanted device so in this case it would be a catheter is placed into the patient's anatomical area of involvement so in this case will likely be the lungs and then at the time of the treatment the ends of the applicator or the treatment catheters that come outside the body those are connected to transfer tubes which are then connected to a commute computer-guided after loader and the after loader is used to direct the position of the radioactive source so the source moves in steps to specific locations in within like the channels that are implanted and then it stops in each of the positions for a specific time as as whatever they calculated and delivers the optimal dose of radiotherapy to the tumor region so what it does is it just minimizes the dose that that's involved to the non involve surrounding tissue and it can get right up to where it needs to be so when the treatments completed the radiation source is retracted back into the after loader and then there's no radiation let's left behind in the patient so there is some nuclear medicine codes that go along with this seven seven seven six one you can see them listed on the screen and those four are for application of intra cabbage intra cavitary radio element so that is that procedure the next codes are three one six four five and three one six four six and that's for therapeutic aspiration um so this it can be done with fluoroscopy to navigate the bronchoscope wherever to wherever that fluid collection is they actually pass a catheter through the bronchoscope and then they can aspirate but that tracheobronchial tree they can also pass a needle through the channel into the fluid collection and aspirate fluid that way three one six four five is for the initial treatment only and then three one six four six is for any subsequent aspiration procedures that are performed during that same hospital stay and they do include fluoroscopic guidance if that's used and as coders ideally we should really insist on documentation of an actual condition such as mucus plugging in order to really confidently code for this therapeutic aspiration if you're questioning it this might want to be one of the if you're questioning the diagnosis this might be one where you'll have to query the provider to make sure there really is a diagnosis of a condition that would warrant this there is another procedure for a catheter aspiration of tranquille bronchial tree that's three one seven two five that's a procedure I've I've moreso seen done in like an outpatient clinic so this therapeutic aspiration is done with a bronchoscope or through a bronchoscopy procedure um this next procedure is bronchial valve service bronchial valves are inserted to treat disease or damaged lungs by limiting airflow to the selected Airways so once the valve is in place and you can see we have a pig picture of a valve here once the valve is in place the airflow is limited to the portions of the lungs that are distal to the valve but it still allows for mucus and air movement and the lungs that are proximal to the valve so in cases of persistent air leaks the bronchial valve limits the air flow to the injured tissue like if there was entered tissue over here that allows for healing and it shortens the duration of the air leak so these codes include assessment of the airway sizing the air leak the balloon occlusion if performed an insertion of that valve and that initial valve is reported with three one six four seven and there's an add-on code if you're moving into additional lobes three one six five one and then following three one six five one there let's go three one six I'm sorry these are a little out of order so when you look at your book it's kind of hard to follow I tried to put them more in a logical order here three one six four eight is for removal of the valve and then if they're removing valves from additional lobes that one's three one six four nine sorry there's a typo on that last code should be three one six four nine um if they do removal and insertion of a bronchial valve at the same session you can report both there's actually a no instructional parenthetical note after that after code three one six four eight that instructs you to do that so that is all of those codes these this next slide goes over some examples so for three one six four seven this would this is a patient with a persistent air leak after surgical resection which has not resolved with chest tube suction for several days so they use bronchoscopy to identify the leak and then they place a bronchial valve three one six four eight they have a patient has an endo bronchial valve placed in a single lobe for control of persistent leak and then they indicate that removal as needed so the three ones explored is for removal three one six four nine the patient had a valve placed in more than one lobe and then removal of all the valves is indicated so the first valve is going to be reported with three one six four eight and then the second one that's now removed is three one six four nine so interesting these these endo bronchial valves they're used to select selectively collapsed lung segments by allowing air out of but not into the area served by the bronchus where the valve is placed so in emphysema this allows other areas of the lung to expand more and work better this is actually a less invasive alternative to surgical excision of lung tissue for the same purpose so you kind of see as we as our medicine gets less and less invasive this is one of the types of procedures that they have come up with which is pretty cool I've mentioned the computer assisted image guided navigation or navigational bronchoscopy a couple times now this is an add-on code it's add-on code three one six to seven it describes doing bronchoscopy with a computer-assisted image guided navigation so this is I've almost always seen it called navigational bronchoscopy it's a 3d road map that lets the provider maneuver through the different branches to really reach targeted lesions in the distal regions of the lung it's designed to be used with just the standard bronchoscope and it just fits it can facilitate with tissue samples placing die markers are really just getting to where ever they need to be so this is an add-on code it can be reported with you see the codes listed here can be reported with a lot of our different bronchoscopy codes so if that's documented it can be reported separately the next procedure is for endo bronchial ultrasound or EBUS EB us these codes were new in 2016 it's a fairly new technology this B bus it's designed to just enhance visualization it's it's another diagnostic pathway so what they can do with IBAs they can differentiate between vascular and nonvascular structures it can provide guidance so like for a trans bronchial needle biopsy they can assist in assessment so they can look at a tumor volume and address feasibility of intervention so if they were looking at airway recanalization um when you look at the codes to report it you will see that three one six two five that is gonna be for trans trachea or trans bronchial sampling and it's gonna be for one or two mediastinal and/or hilar lymph node stations or structures so the stations or structures is really the key factor here when you're counting them so multiple passes at the same station are gonna count just as that one station regardless of how many nodes or structures at that station but each new station sample counts as an additional station so you can report either code three one six five two or three one six five three but you would never report those together three one six five four is a little bit different it's an add-on code and it's used if during the bronchoscopy diagnostic or therapeutic and for interventions they use it for peripheral lesions so it's gonna be it's not gonna be the high low or the medial the mediastinal lymph nodes it's gonna be a peripheral lesion that they're looking at and you will report that again it's an add-on code so you can use it with all of these different bronchoscopy procedures so regardless you're gonna only report once first session for any of these codes okay and this is our the last of our actual CPT codes for this section it is bronchial thermoplasty or BTW this is also kind of a new technology it's used to treat severe or persistent asthma so as you guys know asthma is a chronic condition of the Airways causes breathlessness coughing wheezing that chronic airway inflammation can actually lead to a thickness of the airway smooth muscle which causes the airflow restriction and the difficulty breathing so if you look on this picture here you can see this muscle is way bigger than the normal muscle and this one also has mucus in it but that thick the the treatment here is really aimed at reducing the thickness of this muscle in a then a the bronchial thermoplasty improves the patient's breathing capacity by limiting the ability of that airway to restrict so it's a pretty cool therapy and it's shown to be very highly effective the asthma patients who have gone through this have really demonstrated significant improvement it reduces the severe asthma flare-ups and emergency department visits usually performed as an outpatient procedure and then a full course of the bronchial thermoplasty includes three separate procedures so there'd be one for each lobe of the lung and then another for both upper lung upper lobes and they usually perform the procedures about three weeks apart and they do it do do this under sedation as well so this is a this picture shows where they are introducing that the bronchoscope and then they are giving the thermoplastic off right there so you can see into the airway there so pretty cool um so the next slide is another FAQ this is in CPG assistant has actually been in CPG assistant a couple of different times the question is our bronchoscopy codes bilateral or unilateral three one six two two which again that's kind of our base code our starting code the diagnostic procedure it's considered to be a bilateral procedure so you would not report with modifier 50 bronchoscopy codes are considered to be bilateral however there are some of those bronchoscopy codes which we just went over that allow you to report an additional procedure performed if it's on an additional lobe or an additional bronchus during that same session so that's that question and then we're kind of moving into our NCCI guidance now so I wanted to review this for you guys when you're reporting different bronchoscopy procedures that are performed during the same session on the same patient you'll want to be sure and check in CCI and we can go through some different scenarios here but and this one if two regions of the respiratory are examined at the same time it can be reported if it's medically reasonable and necessary and the endoscopy endoscopic procedures are performed on two regions of the respiratory system with different types of endoscope so in this example they did a diagnostic bronchoscopy for a lung mass and then they did a fiber off or well they did that with a fiber-optic bronchoscope and then they did a separate laryngoscopy for a LAN geo mass with a fiber optic laryngoscope so two separate scopes but they were both medically necessary both had different diagnoses they were looking at those could be reported separately oftentimes a fiber-optic bronchoscope they'll go ahead and look at the nasal cavity the fairness the larynx kind of on their way down that's not reported separately that would be just like a limited or a cursory exam so it'd have to be medically necessary to separate exams to separate scopes used and then we have a bunch of guidelines about what happens in certain scenarios where procedures are converted so let's just go through these and then we're gonna go through some coding examples with some questions along the way the first scenario is the findings of a bronchoscopy lead to a decision to perform a non bronchoscopic surgical procedures like an open procedure in that case you can report the diagnostic bronchoscopy separately the next one is a scout bronchoscopy is used to evaluate the surgical field prior to an open procedure so in this case they had already decided to do an open procedure but they're doing like a quick bronchoscopy Scout before they do the procedure in that case do not report that diagnostic bronchoscopy the next one bronchoscopy is performed at the same encounter as a non bronchoscopy procedure to ensure no intra operative injury occurred or to verify the procedure was performed correctly that kind of goes along with the scout bronchoscopy though that's not that diagnostic bronchoscopy is not gonna be reported separately the next one bronchoscopy is performed with a surgical bronchoscopy do not report the diagnostic bronchoscopy bronchoscopic procedure fails and it's converted to an open procedure again do not report that bronchoscopy procedure whether it's surgical or diagnostic you'll only be reporting that open procedure so let's look at a few examples here pretty quick um the first one is the patient presents for an aspiration of foreign body bronchoscopy is performed the foreign body is identified foreign body is removed during the bronchoscopy I'm gonna ask you guys this question in that example that we just discussed do you report both that diagnostic bronchoscopy and the removal of the foreign body are you gonna report both of those codes I just popped it up on your screen so you can let say no thank you yeah it's a yes-or-no question do you report both of them or not perfect since we're getting close on time and I know you got another example anybody else want to weigh in I'm gonna close it and let Shay see the results okay Shay 90% is saying no you do not report both yep you you guys are correct in this case you only report that surgical bronchoscopy code the 360 35 the removal of the foreign body so continuing on with this example they do the bronchoscopy foreign body is identified they attempt to remove the foreign boss foreign body but it fails so they decide to do a thoracotomy so in that case what do we report do we report the diagnostic the surgical foreign bot and the surgical foreign body removal and the thoracotomy do we report only the thoracotomy or do we report the diagnostic bronchoscopy and the thoracotomy I just launched it so you guys can answer right on your screens so Shay wants to know what do you report for this case great we've got responses coming in pretty quick Shay yeah that's good this is kind of tricky so think about it a little bit okay I'm gonna close it three two one okay Shay you can see we've got 74% is only coating the thorah caca thorocotomy sorry and then we've got kind of split on the top one and the bottom choice okay Soper in ceci sat in CCI only the surgical endoscopy so in this example the the endoscopic effort fails and the thoracotomy is performed so the diagnostic bronchoscopy can be reported separately in addition to the thoracotomy so you guys that chose that third example are correct and that went along with our first kind of that first bullet on this slide when I was going through these so that's four in CCI they can report the diagnostic bronchoscopy but not the surgical procedure all right and have one more patient presents for aspiration of foreign body bronchoscopy is performed foreign body is identified they made an attempt but failed they decide to do a thoracotomy but before they do the thoracotomy they repeat the bronchoscopy after anesthesia induction to confirm the surgical approach to the foreign body so last question here is is that confirmatory bronchoscopy reportable and this is pretty easy question I mean your choices are limited okay it's not an easy question but you only know right unlike the last question I think that was a little trickier yeah that last one was tricky okay I'm gonna close the poll in three two one okay Shea 79% said no it's not reportable you have almost 21% is saying it's yes so we still got quite a few people saying yes yeah so no it's not reportable um so if the surgeon decides to repeat the bronchoscopy after induction of general anesthesia to confirm that surgical approach does cert that cough confirmatory bronchoscopy that's not separate really reportable although the initial diagnostic bronchoscopy that can still be reported just a few more guidance from NCCI control of bleeding is gonna be integral that's not separately reported they use an example specifically of nasal hemorrhage so 309 o1 that's not separately reportable if that happens with any kind of endoscopic procedure or bronchoscopy and then they also say if multiple services are reported at the same time and are not adequately described by a single CPT code you can report more than one code so we've kind of been talking about that as we go I also wanted to touch just real quick on Medicare endoscopy family and payment rules so there is special pay although you can report all these procedures you won't get paid out 100% for all of them so I wanted to touch on that there's special payment rules for multiple endoscopy is performed on the same day during the same operative session so this just shows the process of reimbursement here these indicators can be found on the Medicare physician fee schedule indicator list and what we're looking at here is this category in and you can see the ones with threes are in the same family and then this is their base code so three one six two two is the base code so how this works is if in my example here we're reporting three one six four one and three one six four five so you can see these both have indicator three so that means they're in the same family and then this is their base code three one six two two so the first procedure three one six four five that has the highest allowed amount so in this case 267 forty-one so it'll be paid out one hundred percent to 67 forty-one this next code three one six four one what they do is they take the base code allowed amount which is two forty six forty one and then you're paid the difference between the allowed amount and that base code or the mother code so in this case the difference between the two codes is 1982 so that's what you would get paid for that code so although they allow you to separately report them all you're gonna get paid a little bit different um for those and that is the end of the presentation here's my references if you look curiously rule you can look at that minor surgery an endoscopy website and it'll explain that further and here's my website or my sorry my email if you have any questions I don't know if we have time for a question today but if you guys submitted them we could surely get them answered right Kathy absolutely and we are at the top of the hour actually one minute over so I will compile all the questions I will submit them to che and then what we will do is provide you a link and we will create the video and publish it out to our YouTube channel so that we do address all the questions that came in so I want to thank you Shea for a wonderful presentation and I want to thank our audience for spending the last hour with us so as she mentioned feel free and email che with any questions we will publish out the FAQ s within this week as well as give you the link to the recording sometime by tomorrow so thank you very much we hope you enjoyed the webinar please take a couple minutes to fill out the survey that will pop up on your screen and we hope to see you either next week for the PCs side of bronchoscopy s or next month for next month's webinar again thank you very much have a great afternoon everyone bye-bye you