Hi. This is Cindy. Today we're going to talk
about Chapter 4, the Respiratory System.
The first procedure we will look at are
the nasal sinus endoscopies. These allow
the physician to visualize the interior
of the nasal cavity, all the various parts
and that is diagrammed for you in Figure
4.9 in your CPT textbook (2017). Endoscopy can
be diagnostic or surgical and
we're going to take a look at
the guidelines in the CPT code book. I've
reproduced the color structure there in
the CPT book where the red font
represents a part of the respiratory
system. Then the endoscopy represents
the type of procedures that you're
looking at. We have guidelines here.
I've underlined several things. One is
that a surgical endoscopy includes a
diagnostic endoscopy so you're not
going to code the diagnostic endoscopy if you're
having a surgical endoscopy The codes do describe
unilateral procedures so you'll have to
add a -50 if you're having the
procedure on both sides of the
nose.We're going to look at Exercise 4.15
Exercise 4.15 #2- a left nasal endoscopy for
control of epistaxis. Epistaxis is severe
bleeding, nose bleeds.
Here's the code, the modifier, as well as
the path. You can use Endoscopy as
your main term or the nose, either way
gets you there. Don't forget your
modifier. The final code 31238
and I show you here from the
code book the parent code "nasal sinus
endoscopy, surgical" and then the final
code 31238 with
control of nasal hemorrhage. You see
how I've drawn a half circle around
those two codes and the arrows. The
arrows tell me that on the next page is
a continuation of this family of codes.
Now we'll look at the laryngoscopies.
Following the same color format of the
CPT code book, the larynx is the part of
the respiratory system we're looking at.
Endoscopy, the type of procedure and an
endoscopy on the larynx is called a
laryngoscopy. There's two slides here
that have the guidelines and I've
highlighted things there, made a couple
of notes.
Note that the paired structures, and it
tells what they are. For the
purpose of reporting therapeutic
interventions, all paired structures
contained within one side of the larynx
are considered unilateral. That's
important to know. If you're using an
operating microscope, telescope or both,
you're going to use the applicable code
only once per operative session. (These are) general
guidelines but still important to read
them. So the questions we want to ask
ourselves before we assign a code for
laryngoscopy, What's the purpose of it?
Which type is being used? The types
are direct, indirect, and flexible fiberoptic.
Is a stroboscopy used?
Astroboscopy is like a strobe light. It
really enhances what the physician can
see. It is used on some of the
laryngoscopies. Here's our first
question, Exercise 4.17 #2
A flexible fiberoptic laryngoscopy
performed for removal of a dime lodged
in the patient's larynx. The purpose
is to remove the foreign body. The type?
It tells us it's a flexible. Does it
mention the stroboscopy? No. So here we
have the code, the path that was used.
Here we have the parent code on the left
and you can see where that came from>
The final code 31577 on the right. You
see the parent code is laryngoscopy,
flexible, diagnostic. 31575, that's the
parent code. It's at the bottom of one
page, so I have my half circle around the
family with my arrows. Then I come to
the next page and you see I have my
arrows now going up to tell me that
before these codes, the family of codes
is on the previous page. I just wanted to
show you, using the split screen here, how
I make sure that
I'm looking back far enough to find that
parent code. Here's an indirect
laryngoscopy with a biopsy so the
purpose is a biopsy, it's indirect and
no stroboscopy is mentioned. It's pretty
straightforward. Here we go. Your
parent code is the laryngoscopy, indirect
diagnostic but in our case, we are using
it for a biopsy so our final code is 31510.
So now let's look at the endoscopy,
use of the bronchi which is called a
bronchoscopy. The red font tells you I'm
in the Trachea and Bronchi section of
the Respiratory System. The endoscopy is
the type of procedure we are
looking at, so a bronchoscopy is an
endoscopy of the bronchi. I mentioned
here, it's mentioned in the guidelines
the surgical bronchoscopy includes a
diagnostic bronchoscopy when it's
performed by the same physician. The
range of codes that are given there
includes fluoroscopic guidance when it's
performed. Two codes are mentioned 652
and 653 as complete services used for
sampling lymph nodes or adjacent
structures utilizing EBUS and are
reported separately. Last of all code
31654 is an add-on code used for
reporting one or more peripheral
lesions with transendoscopic ultrasound.
So the questions you're going to answer
before you assign a code for a
bronchoscopy is: Why was it done? Was it a
diagnostic done in conjunction with a
surgical? If so, you're only going to code
the surgical. Was the procedure one of
the bronchoscopies is described by a code
from the series 31622 through 31651?
If so. fluoroscopy or fluoroscopic
guidance is considered part of the
procedures within that range of codes.
Here you see Exercise 4.19 #2
bronchoscopy with a transbronchial
biopsy of the lung. Why was it performed?
A biopsy of the lung. Surgical or diagnostic? It
is diagnostic because we're trying to
figure out (what is wrong). When you are doing a biopsy of
something, you're trying to figure out if
it's cancer, most of the time. Is code in
the range 31622 through 31651? If so,
fluoroscopic guidance is considered part
of the procedure. There we have the code,
the way it's described in the codebook.
Bronchoscopy was the main term we looked
at in the index and looking here we see
the parent code 31622 on the previous
page and I'm just showing you how i got
to 31628. The answer is 31628 but I want
to make sure that you understand that I
am going back to the parent code and
then I start looking under there and
that is in the range of codes that the
index tells me to look at. I've selected
31628 as my answer. Also notice I
have an asterisk here. It says 31628
should be reported only once
regardless of how many lung biopsies are
performed, so just keep that in mind too.
It's in the lobe, how many lung biopsies
are performed in a lobe. I have to force
these screenshots to make two
of them fit on the slide, so that's why
they are distorted. My apologies for
that.
Now let's look at a bronchoscopy with an
EBUS guided transbronchial sampling of
two mediastinal lymph nodes. I have
everything in the purple font because
every word in that is important.
An EBUS
is an endobronchial ultrasound.
It's used to diagnose anything that
would cause enlarged lymph nodes in the
chest. So here I have the code as well as
the index. Here you see the code 31652.
I didn't bother to put the parent
code on this one, but I think you've
got my point now. Whenever you see those
half circles with the arrows, it tells
you that the parent code was in a
previous column at the bottom of the
page. I did make a note for myself to
report it once per session, no matter how
many bronchial samplings are taken. You
do notice too that this specifically
says a mediastinal and/or hilar lymph
node stations or structures. So it is
looking at specific lymph nodes.
Exercise 4.20 #2 is an
operative report in your textbook (2017) and
these are the answers.
Exercise 4.21 #2-Percutaneous
drainage of pleural cavity via
indwelling catheter with imaging. I
wanted to tell you that the main term
for drainage is "puncture" because you
have to actually go through that
covering over the pleural cavity to place
your catheter. That is done with
imaging so that you don't puncture
anything you don't want to. Here's your
code and your index path. I want to show you
this slide because it's kind of like a
warning. you see code 32556 is up
here and 32557 below the diagram and
the thing is the diagram is about
something completely different. The
diagram has split a family of codes and
is placed right in the middle of codes
it doesn't even apply to. So be extra
careful when you're looking at diagrams
to be sure you are looking at the
diagram you want to look at and the
associated codes because that could
really get you in trouble if you thought
that the thoracentesis was one of
these two codes above or below the
diagram, because it isn't. Here it is.I
took, this is below that diagram, I wrote
the parent code plueral drainage
percutaneous with insertion of indwelling
catheter and what made it correct is it
adds "with imaging guidance" 32557.
Exercise 4.21 #4 is a flexible
bronchoscopy with bronchial brushings
and cell washings. Why is it performed?
For cell washings. Surgical or diagnostic?
Diagnostic. Is fluoroscopic guidance
included? Yes. Here are your codes. You
notice that bronchoscopy and brushings
are separate from the code for cell
washings. Here's those two codes 31622
are your cell washings and 31663 are
your brushings. I should have put both of
those in the title there. In our next
problem, (Exercise 4.21 #6) the patient was treated in the
emergency department for severe
epistaxis. This is another of those severe
nosebleeds. The physician
is performing extensive anterior packing,
bilateral so the significant words are
the packing and the extensive and
bilateral. So when you look in the index.
under packing. there is a code for nasal
hemorrhage. You can also find it in a
roundabout way using epistaxis or
hemorrhage. You know that our
documentation tells us that it is
extensive. There's no way you could know
unless the doctor said so, whether or not
it was extensive and don't forget
modifier-50 for the fact that it was
performed bilaterally. Here's that
code 30903 and you note that "extensive"
is part of your description and also
that reminder about if it's bilateral, to
add the modifier -50. A revision of
a tracheostomy scar is one of those
"Other Procedures" that are mentioned in
our textbook. There it is 31830 and here
it is. I have it underlined in the CPT
code book.
Whenever I have a code that's a single
code without codes under it, I just do a
little underline that tells me that it
stands alone. Next, the patient has a
history of persistent hoarseness. Surgeon
performs a flexible fiberoptic
bronchoscopy to evaluate the larynx. So
the purpose of this laryngoscopy? It was
diagnostic. What type is being used? It's
flexible. Stroboscopy was not used. So
here is your code 31575. Here we have
it from the CPT code book. Okay, if you
have any questions about any of the
problems on this podcast or from your
textbook, please place them in Discussion
Board along with the path that you used
to try and find them. Thanks so much and
have a good evening.