1. Respiratory System
By Alex Munoz, CPC, NCICS

2. 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

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

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

5. 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..

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

7. 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

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

9. 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

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

11. 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

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

13. 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

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

15. 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

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

17. 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

18. 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

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

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

21. 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

22. 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 (nasopharyngoscopy with endoscope) is bundled into any respiratory procedure performed at the same session

23. 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)

24. 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

25. 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

26. Laryngotomy: open surgical procedure to expose larynx
Larynx, Excision ( )
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

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

28. 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

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

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

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

32. 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

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

34. 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

35. 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

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

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

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

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