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Code This!

Scenario Week of June 28, 2012:
View Current Scenario

Preoperative Diagnosis: Shortness of breath, chronic cough, and weight loss

Postoperative Diagnosis: Same

Operation: Bronchoscopy

Indications:

A 55-year-old male presents for bronchoscopy. The patient has a 40 year pack-a-day history of smoking and is complaining of shortness of breath, chronic cough, and weight loss.

Plan: Bronchoscopy

Procedure:

After satisfactory preoperative medication with 0.2 mg of Robinul and 1 mg of Ativan IM, the posterior pharynx was topically anesthetized with 1 percent nebulized Lidocaine and the nasal mucosa was further anesthetized with 1 percent topical lidocaine.

Vocal cord structure and function were normal. The tracheal bronchial tree on the left hand side revealed distortion of the carina separating the upper lobe and lingula from the main stem of the bronchus. There were no ulcerations of the mucosa but the anatomy was distorted.

Using fluoroscopic guidance, four biopsies of the left upper lobe mass were accomplished along with washings and brushings.

The patient tolerated the procedure well with oxygen saturation being greater than 92 percent for the entire procedure, pulse in the 80s, and blood pressure controlled. Postprocedure chest x-ray showed no pneumothorax and the patient and family had the findings of this procedure discussed.

Code this!


Answers:

CPT Procedures:

  • 31625 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites
  • 31623-51 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushing

Rationale:

Conscious sedation is considered an inherent part of the procedures performed; therefore, the anesthesia provided by the surgeon is not reported separately. Medical record documentation indicates that the physician performed bilateral biopsies under fluoroscopic guidance. This is reported using 31625. Note that the procedure description indicates single or multiple sites; therefore, the code is reported only once even though multiple biopsies were taken. The operative report also indicates that washings were performed, which is reported with 31623. According to CCI edits, 31623 may be reported separately with 31625. Modifier 51 Multiple procedures, is appended. Because surgical endoscopies include a diagnostic endoscopy, 31622 is not reported separately.

ICD-9-CM Diagnoses:

  • 786.05 Shortness of Breath
  • 786.2 Cough
  • 783.21 Weight loss
  • V15.82 Personal history of tobacco use, presenting hazards to health

Rationale:

The documentation does not provide a final, definitive diagnosis; therefore, the patient’s symptoms, as well as the personal history of tobacco use, are reported. It should be noted, however, that it would be advisable to wait until the pathology report is available to report a more specific diagnosis.

In the event that the procedure needs to be reported without the pathology report, the following process could be used. For the diagnosis of shortness of breath, the correct code is found in the ICD-9-CM index under the main term “shortness” and the subterm “breath,” which references code 786.05.

For the diagnosis of cough, the correct code is found in the ICD-9-CM index under the main term “cough,” which references code 786.2. In the tabular listing of ICD-9-CM, 786.2 has an “excludes” note that lists several codes, including a code for “smoker’s cough”. Although the patient is a smoker, the physician did not specifically document “smoker’s cough” as the diagnosis so the use of that code would be inappropriate. The appropriate code choice for this particular patient would be 786.2.

Next a code is assigned for the patient’s weight loss. The correct code is found in the ICD-9-CM index under the main term “loss” and the subterm “weight.” The index entry states “weight (cause unknown)” and references code 783.21. This would be the correct code because at the time of this procedure the cause of the weight loss is still unknown.

Next a code is assigned for the personal history of tobacco use, which is described by a “V” status code. The correct code is found in the ICD-9-CM index under the main term “history of” and the subterm “tobacco use,” which references V15.82.

 
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