Troubleshooting Your Bronchoscopy Coding
Carol Pohlig BSN, RN, CPC
Reimbursement Analyst, Office of Clinical Documentation, Department of Medicine
University of Pennsylvania
Coding bronchoscopy procedures can be challenging. There are so many factors to consider when generating a "clean claim." Overlooking one small detail can negatively affect your reimbursement. Maximize your revenue opportunities by incorporating the following strategies when coding bronchoscopies.
Reporting Multiple Procedures
Code what you do. The bronchoscopy codes (31622-31656) represent separate procedures. Code 31622 describes a diagnostic bronchoscopy procedure, with or without cell washings. The remaining codes (31623-31656) describe the diagnostic and therapeutic measures that can be performed via the bronchoscope. Several of these procedures can occur during one bronchoscopy session. For example, a pulmonologist performs a bronchoscopy on a patient presenting with increased coughing, chest pain, dyspnea and weight loss. During the procedure a lesion and a separate area of suspicion are noted in the right lower lobe. The physician obtains a biopsy, washings and brushings. It is appropriate for the pulmonologist to report codes 31625 (bronchoscopy with biopsy) and 31623 (bronchoscopy with brushing or protected brushings) together on the claim. The diagnostic bronchoscopy, with or without cell washings (31622) cannot be included on the claim with the therapeutic interventions (31625 and 31623). According to Current Procedural Terminology (CPT) coding guidelines, the diagnostic bronchoscopy is always incorporated into the surgical (i.e., diagnostic or therapeutic) bronchoscopies reported by the same physician [during the same session].
Correct coding guidelines for CPT require you to append a -51 modifier (multiple procedures) on all subsequent procedures listed on a claim, unless otherwise specified. Therefore, the codes are reported as follows: 31625, 31623-51. Your local Medicare Carrier may instruct you not to append modifier -51 when reporting multiple endoscopies since the method of reimbursement varies from other types of procedures reported together. Most other insurers do not have electronic systems that recognize modifiers. It is important to check with the insurer and identify the preferred coding method so that payment will not be denied or delayed.
CPT vs. CCI
CPT guidelines sometimes vary from the guidelines set forth by the Health Care Financing Administration (HCFA) for Medicare. When this occurs, it is imperative to follow HCFA's instruction. Section 15068 of the Medicare Carrier Manual describes HCFA's usage of the CPT Coding System to identify physician services and procedures with the application of additional coding policies and principles in the review of all Medicare claims.
One of the most explicit examples of this variance is the Correct Coding Initiative (CCI), an edit system developed for HCFA that limits or prohibits reporting certain procedures together. New edits are implemented on a quarterly basis. Keeping updated on the edits can help you to submit claims more appropriately and avoid unnecessary denials.
According to CPT, any combination of therapeutic bronchoscopies can be reported together, as long as a diagnostic bronchoscopy is not reported and each procedure is only reported once. These edits include reporting a transbronchial lung biopsy (31628) together with an endobronchial biopsy (31625) performed by the same physician on the same date of service. CCI prohibits this code pair unless there are certain circumstances that exist. For example, if the two types of biopsies are performed at different sites of the lung or on different lesions, HCFA allows the code pair to be reported together. In order to alert the Medicare Carrier to the "special circumstances" that allow payment for both procedures, HCFA requires modifier -59 to be appended to the procedure that, under normal circumstances, is not separately reportable. In this case, modifier -59 is appended to the standard biopsy code (31625).
Be aware that all CCI code pairs are not subject to allowable payment under the "special circumstances" scenario. All of the code pairs contained within CCI have a superscript, otherwise known as a "modifier indicator." A superscript of 1 indicates that a modifier (-59) can be applied to allow payment for two procedures not normally reported together. A superscript of 0 indicates that separate payment will not be made regardless of any applied modifier.
Multiple Endoscopy Payment Rules
When submitting your claim for multiple bronchoscopy procedures, list the procedures in order of their value from highest to lowest. Reimbursement for bronchoscopies is rooted in this method. The "value" is derived from either the procedure's Relative Value Unit (RVU) assignment or the Medicare Allowable Payment under the Physician Fee Schedule. For example, one of the coding examples listed above distinguishes 31625 as the primary procedure code and 31623 as the secondary procedure code. This order is designated by comparing the RVUs and/or Medicare Allowable Payment for the two codes. If performed in a facility, code 31625 has 5.52 RVUs (the Medicare reimbursement is $222.90*); code 31623 has 4.73 RVUs (the Medicare reimbursement is $191.04). If performed in a non-facility area, code 31625 has 6.66 RVUs (the Medicare reimbursement is $270.44*); code 31623 has 6.18 RVUs (the Medicare reimbursement is $251.51*). Utilize the facility RVUs reimbursement if the procedure is performed in an inpatient hospital (Medicare's designated place of service 21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), skilled nursing facility (31), inpatient psychiatric facility (51), community mental health center (53), comprehensive inpatient rehabilitation facility (61), or comprehensive outpatient rehabilitation facility (62).
Typically, Medicare reimburses multiple procedures at 100% for the first procedure and 50% for subsequent procedures. However, under the Multiple Endoscopy Payment guidelines, Medicare reimburses pulmonologists at 100% for the first procedure (highest valued) in addition to the difference between the next highest valued procedure less the base (diagnostic bronchoscopy). Payment for the "base" (diagnostic bronchoscopy, 31622) is included in the payment received for the highest valued procedure. For example, payment for procedures 31625 and 31623 is $226.81. You receive 100% of 31625 ($222.90) in addition to the difference between 31623 ($191.04) less the 31622 ($187.13), $3.91.
Non-Medicare insurers may only reimburse you for one procedure or use a different type of payment scale. They are not as straightforward with their guidelines as HCFA. Make sure that you are aware of their methods. You may not be able to change anything until it is time to re-negotiate your contract. At the very least, you will be armed with information.
* HGSAdministrator's Medicare Allowable Payment for Pennsylvania
Articles are selected by Dr. Marinelli with input and review from the ATS Clinical Practice Committee.
The opinions rendered herein are those of the author; no representation, warranty of guarantee of fitness is either made or implied.
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