Q: How do I code for a 31628 for a patient with a tracheostomy (31615)? Should I also code a 31625? Do I need any modifiers?
A: 31628 is defined as a bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe. Although not indicated in the CPT book code listing, CPT Assistant indicates that with a flexible bronchoscopy the scope may be inserted in the nose, mouth, endotracheal tube or tracheostomy tube. This clarification negates the use of 31615 which is a code for a tracheobronchoscopy through an established tracheostomy incision and does not account for the work of the transbronchial lung biopsy.
Jill M. Young, CPC, CEDC, CIMC, is president of Young Medical Consulting LLC in East Lansing, Mich., and the 2009-2010 Chair of the American Academy of Professional Coders Chapter Association.
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