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Diagnostic Procedures Via the Bronchial Tree
By Cheryl M. Manchenton, RN, BSN, and Audrey G. Howard, RHIA

Treating lung conditions can be challenging without confirmation of the specific disease process. Pulmonologists often use noninvasive diagnostic techniques such as chest x-rays, CT scans, MRI, and positron emission tomography scans, which show anatomical features. However, these tests are limited because they do not reveal morphology (the chemical or cellular composition) of diseases or conditions. Examples of more specific but noninvasive tests include sputum cultures and functional lung capacity studies such as pulmonary function tests. A sputum specimen is very limited, as it is usually able to identify only organisms involved in infections and is not as helpful in diagnosing or clarifying lung diseases or conditions.

A definitive diagnosis is not always possible without more invasive diagnostic studies. For the purposes of this article, we will discuss only those diagnostic procedures via bronchoscope, not thoracic or transthoracic approaches.

The simplest method to obtain a specimen is via bronchoscopy in which there is direct visualization of the bronchial system of the lungs. A bronchoscopy without specimen collection is assigned to one of the following ICD-9-CM codes:

• 33.21, Bronchoscopy through an artificial stoma (eg, tracheostomy);

• 33.22, Fiber-optic bronchoscopy; and

• 33.23, Other bronchoscopy (includes rigid).

The above codes are for procedures that do not impact diagnosis-related groups (DRGs).

Occasionally, the physician will obtain only a direct suction of sputum or mucus without using irrigation or saline through the bronchoscope. This is not the same as a brushing, washing, lavage, or biopsy. Therefore, the correct code assignment remains the one for the bronchoscopy as listed above.

Since suction of the sputum is limiting for a definitive diagnosis, the physician will attempt the next least invasive approach: specimen collection via bronchial washing or brushing (33.24). During a bronchial washing, sterile saline is flushed over the bronchus, suctioned back into a container, and sent to pathology. During the flushing and suctioning of the saline, superficial cells on the surface of the bronchus, etc flake off and are in the sample sent to pathology. It is then tested for both organisms and disease processes/conditions.

During a bronchial brushing, a cytology brush is inserted through the bronchoscope and the surface of the bronchus is gently brushed, thereby scraping off cells that are then sent for study. If the specimen is obtained via bronchoscope by broncho-alveolar lavage or brushing, the code assignment is 33.24, another procedure that doesn’t impact DRGs.

Again, the above tests are minimally invasive, and only endobronchial cells or sputum can be obtained. Frequently, the specimens are suboptimal for pathologic determination, so more invasive tests must be performed. The key to code assignment is determining what type of tissue was obtained (and/or the type of tissue that was intended to be obtained) and the method.

Endobronchial may describe either the approach or the actual tissue obtained/intended to be obtained. Thorough review of the entire operative note is essential. An endobronchial approach may be used to obtain endobronchial tissue or as an approach for more invasive sampling of lung tissue or mediastinal lymph nodes due to their anatomical location and easy access.

When an endobronchial tissue biopsy (33.24) is obtained, a small snippet of tissue is collected from the wall of the bronchus via bronchoscopy forceps. This tissue may indicate a problem within the bronchus (such as inflammatory or allergic bronchitis) or may be able to determine other conditions of the lung (such as cancer or conditions such as fibrosis or sarcoidosis).

Increasingly, a lymph node biopsy is being obtained via the bronchoscope. Certain diseases of the lymph system may be diagnosed or determination may be made regarding systemic/local metastasis via this relatively easy and nonpainful approach. Although it may be described as an endobronchial lymph node biopsy, it is actually a transbronchial lymph node biopsy because the biopsy needle travels across (completely through) the bronchus to the lymph nodes. The code for lymph node biopsy is 40.11, Biopsy of lymphatic structure, which pertains to any approach for lymph node biopsy (open, closed, needle, or transbronchial). Code 40.11 is a valid operating room procedure that will impact the DRG assignment.

Transbronchial lung biopsy (33.27) is assigned when a sample is taken endoscopically through the bronchus from actual lung tissue. This is considered a gold standard diagnostic test for lung conditions and diseases, providing an adequate specimen is obtained. The challenge is placing the forceps deep enough to transect bronchial tissue and obtain lung tissue. Frequently, pathology findings seem to contradict what procedure is performed because it describes only bronchial tissue. Current Coding Clinicadvice indicates the absence of lung tissue in the pathology report does not preclude the assignment of code 33.27 if the procedure note clearly documents that the provider performed a transbronchial lung biopsy. Tissues samples may have been inadequate or inconclusive (AHA Coding Clinic for ICD-9-CM, 2011, first quarter, page 18 and 2011, third quarter, page 7). Code 33.27 is a valid operating room procedure that will impact the DRG assignment. Please note a brush biopsy of the lung is classified to code 33.24. This is not considered a transbronchial biopsy of the lung and therefore is not included in code 33.27.

Procedures that do not mention a transbronchial lung biopsy but note a biopsy of “lobe” or “subsegmental tissue” can lack clarity to determine whether the biopsy was of the bronchus of that portion of the lung or of the lung itself. Further clarification may be necessary and is recommended.

Physician documentation can be inconsistent or vague regarding endobronchial and transbronchial biopsies. Because only transbronchial lung biopsies (33.27) “impact” DRGs and result in the assignment of a surgical Medicare severity-DRG, those procedures assigned to 33.27 are increasingly being selected for scrutiny by quality improvement organizations, recovery audit contactors, and other auditors.

Coding and sequencing diagnostic procedures via the bronchial tree are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— Cheryl M. Manchenton, RN, BSN, is an inpatient consultant for 3M Health Information Systems, consulting on clinical documentation improvement. She has more than 20 years of experience, including policy and procedure development, ethics, staff education, and development of performance and quality improvement initiatives.

— Audrey G. Howard, RHIA, is a consultant with 3M Health Information Systems. She consults with hospitals across the country on coding validations, coding education, coding process improvement, quality and compliance reviews, and clinical documentation improvement initiatives. She has more than 20 years of HIM experience and is the author of For the Record’s Coding and Transcription column.