Respiratory System By Alex Munoz, CPC, NCICS

Respiratory System Further subdivided by procedure Anatomic site arrangement Nose Larynx Further subdivided by procedure Incision Excision Introduction Removal of foreign body Destruction Endoscopy Other procedures

Endoscopy Endoscopy in all subheadings except Nose Each preceded by “Notes”

Endoscopy Rule One: Code full Extent Example: Procedure begins at mouth and ends at bronchial tube Bronchial tube = full extent

Endoscopy Rule Two: Code correct Approach… Example, for removal: Interior lung lesion via endoscopy inserted through mouth Exterior lung lesion via endoscopy inserted through skin Incorrect approach = incorrect code = incorrect Reimbursement..

Endoscopy Rule Three: Surgical always includes diagnostic Example: Diagnostic bronchial endoscopy begins Identifies foreign body Removed (surgical endoscopy)

Multiple Procedures Frequent in respiratory coding Watch for bundled services Medicare—reference the CCI edits Sequence primary procedure first, no modifier Sequence secondary procedures next, with -51

Bilateral Procedure Bilateral procedures often performed Format for reporting chosen by payer Example: Nasal lavage 31000 x 2 31000 and 31000-50 31000-50 31000-RT and 31000-LT Medicare requires one line item with modifier -50

Laryngoscopic Procedures Uses terms indirect and direct Indirect: Tongue depressor with mirror used to view larynx Direct: Endoscopy passed into larynx, physician directly views vocal cords

Nose (30000-30999) Used extensively by otorhinolaryngologists (ear, nose, and throat specialists ENT) But also used by a wide variety of physicians (Cont’d…)

Nose (30000-30999) When approach to nose: (…Cont’d) When approach to nose: External approach, use Integumentary System codes Internal approaches, use Respiratory System codes

Nose, Incision (30000, 30020) Bundled into Incision codes, drain or gauze insertion and removal Supplies reported separately

Nose, Excision (30100-30160) Contains intranasal biopsy codes Polyp excision, by Complexity “Simple” involves polyps that are easy to remove “Extensive” involves sessile polyps (thick base) More time consuming and requires a greater skill level (30115) Excision includes any method of destruction, even laser Use -50 (bilateral) for both sides Reduction of turbinates, 30140

Nasal Turbinates Nasal turbinates Excision of turbinates are considered unilateral If performed bilaterally, use modifier -50

Nose, Introduction (30200-30220) Common procedures Example: Injections to shrink nasal turbinate tissue Displacement therapy (Saline flush) performed through nose to remove mucus Insertion of nasal button

Nose, Removal of Foreign Body (30300-30320) Divided by whether removal at office or hospital (requires general anesthesia)

Nose, Repair (30400-30630) Many plastic surgery procedures, such as: Rhinoplasty (reshaping nose, internal and/or external) Stated as “revision” or “primary” Rhinoplasty for nasal deformity secondary to congenital cleft lip/palate Septoplasty (rearrangement of nasal septum) Included in a rhinoplasty

Nasal Reconstruction Codes for obtaining grafts for nasal reconstruction surgery are in Musculoskeletal subsection Codes for other procedures on the nose are in Integumentary subsection External approach

Nose, Destruction (30801, 30802) Use of ablation (removing by cutting) Used for removal of excess nasal mucosa or to reduce turbinate inflammation

Nose, Destruction (30801, 30802) Based on intramural or superficial extent of destruction Intramural: deeper mucosa Superficial: outerlayer of mucosa

Nasal Hemorrhage (30901-30906) Code based on: Site of hemorrhage (anterior or posterior) Control was simple or complex If a posterior hemorrhage, was it the initial or a subsequent procedure

Nose, Other Procedures (30901-30999) Control of nasal hemorrhage Packing Ligation Cauterization Anterior packing placed through nose Posterior packing placed at very back of throat Code 92511 (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same session

Nose, Other Procedures Anterior packing When surgery is performed solely to improve the patient’s appearance (no signs/symptoms), it is cosmetic Non-covered under the Medicare program (DX V50.1)

Nose, Other Procedures A balloon may be inserted to further control bleeding Hemorrhage may require the insertion of stents, tampons, nasal catheters, or posterior packing Simple packing with gauze or anterior packing suggests a simple procedure

Accessory Sinuses, Incision, Excision, Endoscopy (31000-31299) Codes for lavage (washing) of sinuses Cannula (hollow tube) placed into sinus, saline solution flushed through Use -50 (bilateral) for both sides Sinusectomy: All sinus contents including mucous membranes are removed Antrostomy: Making an opening into the sinus An “antrotomy” means cutting into the sinus

Laryngotomy: open surgical procedure to expose larynx Larynx, Excision (31300-31420) Laryngotomy: open surgical procedure to expose larynx For removal procedure (e.g., tumor) Sometimes confused with Trachea/Bronchi codes for tracheostomy Used to establish airflow

Laryngoscopy Visual examination of the larynx Flexible lighted tube passed through mouth or nose into larynx

Larynx, Introduction (31500, 31502) Endotracheal intubation is establishment of airway Numerous CCI edits Intubation: Endotracheal intubation involves a tube placed through the nose or mouth, through the pharynx and larynx, and into the trachea to establish an airway

Larynx, Repair (31580-31590) Endoscopy (31615-31656) Several plastic procedures and fracture repairs Laryngoplasty procedures based on purpose Endoscopy (31615-31656) Bronchoscope inserted into nose or mouth Rigid endoscopy performed under general anesthesia Flexible endoscopy performed under local or conscious sedation

Trachea and Bronchi, Introduction (31715-31730) Injection Catheterization Aspiration Transtracheal introduction Some include inhaled gas as contrast material

Trachea and Bronchi, Excision, Repair (31750-31830) Plastic repairs of trachea and bronchi Excision of stenosis/tumors Suturing tracheal wounds Scar revision

Lungs and Pleura, Incision/Excision Biopsy codes in Incision and Excision categories Excisional biopsy with percutaneous needle Incisional biopsy with chest open Includes pneumocentesis and lung removal Segmentectomy : 1 segment Lobectomy : 1 lobe Bilobectomy : 2 lobes Total pneumonectomy: 1 lung

Lungs and Pleura, Incision (32035-32225) Thoracotomy: Surgical opening of chest to expose to view Used for Biopsy Cyst Foreign body removal Cardiac massage

Lungs and Pleura, Excision (32310-32405) Biopsy codes in Excision and Incision categories Excisional biopsy performed with percutaneous needle Incisional biopsy performed with chest open

Lungs and Pleura, Removal (32421, 32422) Thoracentesis: needle or catheter inserted into pleural space for Aspiration (withdrawal) of fluid or air for analysis, to drain pleural effusions, or to re-expand a collapsed lung

Lungs and Pleura, Removal (32421, 32422) Chest tube may be inserted to drain fluid and is reported in addition to aspiration

Introduction (32550, 32551) Includes: Removal (32552) Insertion of tunneled indwelling pleural catheter Tube thoracostomy Includes moderate sedation Removal (32552) Destruction (32560-32562) Chemical pleurodesis or effusion For recurrent persistent pneumothorax or multiloculated effusion

Thoracoscopy (32601-32674) Diagnostic and surgical lung procedures Surgical thoracoscopy always includes diagnostic thoracoscopy

Buck, C. (2010). Step by Step. Elsevier. References: Buck, C. (2010). Step by Step. Elsevier.