Coding Corner: Tips for reporting bronchoscopy procedures

Association of Clinical Documentation Improvement Specialists, May 12, 2016

by Paul Evans, RHIA, CCS, CCS-P, CCDS

Following are some ICD-10-PCS documentation and coding tips for three of the most common (and commonly misunderstood/miscoded) procedures performed via bronchoscopy.

Bronchoalveolar lavage (BAL)
Do not confuse this with the therapeutic procedure whole lung lavage, which is performed to treat pulmonary alveolar proteinosis under general anesthesia. A BAL is performed via a bronchoscope within the lumen of the bronchus, and involves “washing” within the bronchus in order to obtain a sample of fluids. It is coded to the root operation “drainage” because fluids are removed. Lung tissue is not obtained.

According to AHA’s Coding Clinic for ICD-9-CM, Third Quarter 2002, the BAL is usually performed under local anesthesia via bronchoscope and “consists of washing out the peripheral airways and alveoli tissue with a rinsing (sampling) solution. About 150– 250 cc of saline may be introduced into a subsegment of a lobe and then with gentle suction, retrieved. The BAL specimen retrieved is sent to the laboratory for various analyses. Supernatant fluid and cell pellets from BAL are useful in the diagnosis of neoplastic diseases, infections, and interstitial lung diseases. Bronchoalveolar lavage allows the recovery of cells as well as noncellular components from the epithelial surface of the lower respiratory tract. BAL is sometimes referred to as a ‘liquid biopsy.’ This is not the same as whole lung lavage therapy normally done for pulmonary alveolar proteinosis.”

Correct coding: BAL, RLL of bronchus = 0B968ZX. (Note: This does not impact MS-DRG assignment.)

Biopsy of bronchus
A biopsy of the bronchus may be obtained via a bronchoscopy. This may also be referred to as “brush biopsy of lung”; however, this is a misnomer, as this lung tissue is not obtained.

According to Coding Clinic, Fourth Quarter 1992, p. 27, “[t]he brush biopsy is of the bronchus, not the lung. The procedure is performed intrabronchially and samples are taken from within the bronchus and not the alveolar or lung tissue. Bronchial and/or lung brushings are not performed as an open procedure(s). This is different from a transbronchial biopsy where the bronchoscope biopsy forceps actually punctures the terminal bronchus and samples of the peribronchial alveoli (lung tissue) are taken.”

Correct coding: Biopsy, RLL of bronchus = 0BB68ZX. (Note: This does not impact MS-DRG assignment.)

Biopsy of lung
A biopsy of the lung tissue may be obtained via a bronchoscopy. The physician should provide documentation in the record of a transbronchial biopsy of lung parenchyma rather than bronchial material. The wall of the bronchus is perforated.

Correct coding: Excision of right middle lobe-lung = 0BBD8ZX. (Note: This does impact MS-DRG assignment.)

Consider the following key points when querying for accurate documentation for bronchoscopies and/ or assigning the correct ICD-10-PCS code for these procedures:

  • Was the procedure confined within the lumen of the bronchus, or was lung tissue obtained in a transbronchial approach?
  • Remember, the bronchi have lobes, too, so ensure the correct anatomical location for coding purposes—lung versus bronchus.
  • If the intent and scope of the procedure and type of any tissue obtained is unclear, query the physician.

Editor’s note: Evans is manager of regional CDI for Sutter West Bay in San Francisco. He is also a member of the ACDIS Advisory Board and the ACDIS Forms & Tools Library Committee, as well as a frequent contributor to the “CDI Talk” networking group. Contact him at evanspx@sutterhealth.org.