Coding guidelines for Respiratory System

 Respiratory system:

· Biopsy cannot be coded with more extensive procedure.

1. 
   If the Biopsy performed prior to the extensive and decision made to perform extensive procedure then we can bill both separately with appropriate modifier.

   Biopsy Example:

   Patient came with Nasal obstruction and performed biopsy along with nasal polypectomy .

   CPT code 31237 for nasal/sinus endoscopy) shall not be reported with the removal nasal/sinus endoscopy code (e.g., CPT code 31255
   
   Diagnostic Vs surgical endoscopy:

   If the diagnostic to evaluate the access regions, Diagnostic endoscopy always included in therapeutic endoscopy It cannot be reported separately .

   Example

   If an endoscopic anterior ethmoidectomy is performed, a diagnostic nasal endoscopy shall not be reported separately simply because the approach to the ethmoid sinus is transnasal.

   Coding guidelines Diagnostic endoscopy can be coded with other procedure:

   If medically reasonable and necessary endoscopic procedures are performed on 2 regions of the respiratory system with different types of endoscopes, both procedures may be separately reportable

   Example:

   1. If a patient requires diagnostic bronchoscopy for a lung mass with a fiberoptic bronchoscope and a separate laryngoscopy for a laryngeal mass with a fiberoptic laryngoscope at the same patient encounter, both procedures may be reported separately. It should be medically reasonable to bill both procedures separately.

   2. If the findings of a diagnostic endoscopy lead to the decision to perform a non-endoscopic surgical procedure at the same patient encounter, the diagnostic endoscopy may be reported separately.

   3. If the diagnostic endoscopy procedure to access the surgical site or to evaluate the any intraoperative injury occur do not report diagnostic endoscopy separately.

   Endoscopy converted to open procedure:

   If an endoscopic procedure fails and is converted into an open procedure, the endoscopic procedure is not separately reportable with the open procedure.

   How to code for Exploration procedure with more extensive:

   Surgical sinus endoscopy includes sinusotomy and diagnostic endoscopy.

   If the medically necessary procedure is a sinusotomy and a sinus endoscopy is performed then we can code both code separately with NCCI edit modifier.

Important guidelines of Control of bleeding with extensive procedure:

Control of bleeding is an integral component of endoscopic procedures, and is not separately reportable

Example:

1. 
   Control of nasal hemorrhage (CPT code 30901) is not separately reportable for control of bleeding due to a nasal/sinus endoscopic procedure

2. If bleeding occurs in the postoperative period and requires return to the operating room for treatment, code for control of the bleeding may be reported with modifier 78

3. The following procedure cannot be reported with nasal endoscopy or other nasal procedure(more extensive procedure)

• CPT code 30901, CPT codes 30801 (Ablation, soft tissue of inferior turbinate’s…; superficial),
• 30903 (Control of hemorrhage, anterior…),
• 30905 (Control of hemorrhage, posterior…),
• 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage)

Multiple procedure:

If multiple services are performed and are not adequately described by a single CPT code, more than one code may be reported. The multiple procedure modifier 51 should be appended to the secondary service CPT code(s). Additionally, only medically necessary services may be reported. Incidental examination of other areas shall not be reported separately.

Inclusive procedure:

· CPT code 31292 – 31294 cannot be reported with following procedure when performed on the ipsilateral side:

o         31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy;

o         31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus)

o         31276 (Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed),

o         31287 (Nasal/sinus endoscopy, surgical, with sphenoidotomy;

o         31288 (Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus)

· CPT code 30130 is also included and not separately reportable if performed on the ipsilateral side to allow access to the ethmoid or other sinuses to perform the procedures described by CPT codes 31292-31294 However, CPT code 30130 may be reported separately, if performed on the ipsilateral side, for a purpose unrelated to allowing access to the sinuses to perform the procedures described by CPT codes 31292-31294.

· If any of the included procedures are performed on the contralateral side from the procedures described by CPT codes 31292-31294, they may be reported separately.

· Flexible laryngoscopy and direct laryngoscopy shall not be reported for the same patient encounter.

1. 31000, 31002 (Lavage by cannulation of a respiratory accessory sinus) is an integral component when performed with a more definitive procedure on that sinus, If the procedure performed on the ipsilateral sinus at the same patient encounter.
2. If laryngoscopy is required for elective or emergency placement of an endotracheal tube, the laryngoscopy is not separately reportable
3.     CPT code 31500 describes an emergency endotracheal intubation procedure and shall not be reported when an elective intubation is performed.
4.      CPT code 31600 (Tracheostomy, planned (separate procedure) cannot be reported with main procedure.
5.     The laryngoscopy is not separately reportable when It is required for placement of a tracheostomy (31600-31610).
6.     92511 (Nasopharyngoscopy with endoscope (separate procedure)) shall not be reported separately when performed as a cursory examination with other respiratory endoscopic procedures.
7.      A diagnostic thoracoscopy (CPT codes 32601, 32604, 32606) is not separately reportable with a surgical thoracoscopy on the ipsilateral side of the thorax
8.      A diagnostic thoracoscopy to assess the surgical field or extent of disease before an open thoracotomy, thoracostomy, or mediastinal procedure is not separately reportable

· CPT code 92502 (otolaryngologic examination under general anesthesia) is not separately reportable with any other otolaryngologic procedure performed under general anesthesia.

· Diagnostic thoracoscopy is separately reportable with an open thoracotomy, thoracostomy, or mediastinal procedure if the findings of the diagnostic thoracoscopy lead to the decision to perform an open thoracotomy, thoracostomy, or mediastinal procedure. Modifier 58 may be reported to indicate that the diagnostic thoracoscopy and open procedure were staged or planned

Thoracoscopy is converted to an open thoracotomy

· If a surgical thoracoscopy is converted to an open thoracotomy, thoracostomy, or mediastinal procedure, the surgical thoracoscopy is not separately reportable. Additionally, a diagnostic thoracoscopy shall not be reported in lieu of the surgical thoracoscopy with the open thoracotomy, thoracostomy, or mediastinal procedure. Neither a surgical thoracoscopy nor diagnostic thoracoscopy code shall be reported with the open thoracotomy, thoracostomy, or mediastinal procedure code when a surgical thoracoscopy is converted to an open procedure.

Thoracotomy; with exploration (32100)

· It is not separately reported with open thoracic procedures

Thoracotomy can be coded with following reason:

• · It is performed on the contralateral side
• · It is performed on the ipsilateral side through a separate skin incision;
• · It is performed to obtain a biopsy at a different site than the other open thoracic procedure. 

A tube thoracostomy (CPT code 32551) may be performed for drainage of an abscess, empyema, or hemothorax. The code descriptor for CPT code 32551 defines it as a “separate procedure.” It is not separately reportable when performed at the same patient encounter as another open procedure of the thorax unless it is performed in the thoracic cavity contralateral to the one entered to perform the open thoracic procedure.

The following procedure cannot be reported with radiological examination (71045, 71046)

• Pleural drainage procedure (e.g., CPT codes 32556, 32557
• Thoracentesis procedure (e.g., CPT codes 32554, 32555)
• Chest tube insertion procedure (e.g., CPT codes 32550, 32551)

Coding guidelines for Respiratory System

· Both cannot be reported separately if the anatomic location of the biopsy is different than more extensive procedure.