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Billing and Coding for Interventional Procedures. David Ost, MD, MPH Director, Interventional Pulmonology Associate Professor of Medicine Division of Pulmonary and Critical Care New York University School of Medicine. Components of an Interventional Pulmonology Program. Strategic Vision

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billing and coding for interventional procedures

Billing and Coding for Interventional Procedures

David Ost, MD, MPH

Director, Interventional Pulmonology

Associate Professor of Medicine

Division of Pulmonary and Critical Care

New York University School of Medicine

components of an interventional pulmonology program
Components of an Interventional Pulmonology Program
  • Strategic Vision
  • Procedures & Equipment
  • Bronchoscopy Personnel
  • Support Personnel (Pathology, Radiology)
  • Information Infrastructure
  • Billing and the Financial Cycle
  • Research Structure
  • Integrating New Technologies
1 strategic considerations
1. Strategic Considerations
  • Is the economic and medical environment conducive to success?
    • Medical Culture
    • Inside Competition / Outside Competition
    • Referral Base
    • Capital Investment
    • Time Investment
    • Personal Commitment
  • Would a more Limited Goal be Better?
time investment
Time Investment
  • Your time to develop program
  • Your time to go to training programs and seminars
  • Your Career Goals
  • How big a role does bronchoscopy play in your career goals?
  • What are the goals of others and how can bronchoscopy help them achieve those goals?
    • Example: CT fluoro, bench research, MICU
2 procedures
2. Procedures
  • Delineate Procedures for the Lab
    • Routine Bronchoscopy
    • Fluoroscopy
    • On-site Cytology
    • Interventional Bronchoscopy
    • Thoracoscopy

Greater Complexity

4 support personnel
4. Support Personnel
  • Pathology for on-site cytology
  • Radiologist: CT-Fluoro
  • Anesthesia: Rigid Bronch
  • Office Manager: Bronchoscopy Scheduling
  • Biller: Billing protocols
  • Internal Controls and Auditing
5 information infrastructure
5. Information Infrastructure
  • Medical Record
  • Billing
  • Routine QA
  • Assessing Process Performance
  • Research
performance assessment
Performance Assessment
  • Clear Goals in your mind
  • Work up to them with your lab
  • Management requires Measurement
  • Examples:
    • Capacity: # bronchs per day feasible
    • Capacity: # Interventional bronchs/day
    • Quality: Availability of Cytology
    • Financial Cycle and Efficiency
ideal information infrastructure efficiency of data entry
Ideal Information Infrastructure: Efficiency of Data Entry

QA Data

Routine Bronchoscopy Medical Record Entry

Billing Data

Research Data

modularity and connectivity
Modularity and Connectivity

Clinical Record

Micro Lab

Path Lab

Bronch Record

X-ray Record

Hospital IT

critical data pieces for billing
Critical Data Pieces for Billing
  • Indication for Bronchoscopy
  • Detailed bronchoscopy note with all parts of the procedure (brush, BAL, TBNA) for all locations
  • Comorbidities (for hospital billing)
bronchoscopy report software
Bronchoscopy Report Software
  • Alternatives:
    • Commercial Vendors:
      • Bronchoscopy vendors
      • Software Vendors
        • Provation- www.provationmedical.com
        • Utech- www.endosoft.com
        • MD-reports: www.md-reports.com
    • In-house Development
  • Considerations:
    • Formatting, fax, email, user friendly, support services
    • Modularity & Connectivity to other data sources
    • Billing software attached-
      • Sometimes (not just codes but coding support)
      • Billing support updated
    • Research Goals
    • Vendor: Are they fiscally sound? Will they stay in the business?
bronchoscopy billing
Bronchoscopy Billing
  • Multiple Endoscopy Rule
    • NOT the multiple procedure rule
  • Modifiers (CCI edits)
  • Evaluation and Management (E & M)
  • Add-on Codes (ZZZ codes)
billing
Billing
  • Pre-certification as needed
  • Bronchoscopy-
    • Lead code- the most complex (highest number)
    • Multiple Endoscopy Rule:
      • Secondary codes- sometimes with a modifier
      • Example: Bronch with TBNA, Transbronchial biopsy, and BAL.
        • Lead code is TBNA (31629)
        • Also code TBBx (31628) and BAL (31624)
        • Currently, no modifiers are needed for the secondary codes listed here.
modifiers and the multiple endoscopy rule
Modifiers and the multiple endoscopy rule
  • Modifiers (CCI edits) often not required
    • -59 procedure separate and distinct from the primary procedure (e.g. two separate bronchoscopies on the same day; for therapeutic aspiration.)
    • -51 multiple procedures during the same session. Generally not required any more for bronchoscopy. Check with local carrier
modifiers exceptions and examples
Modifiers- exceptions and examples
  • -59 use when you do endobronchial biopsy (31625) and TBNA at the same time (31629).
    • If you do not use a modifier, then you will not get paid for the endobronchial biopsy since it is bundled under 31629
    • Example proper coding: 31629 (lead code is TBNA) and 31625-59 (endobronchial biopsy).
  • NOTE: Endobronchial biopsy requires a modifier with TBNA but TBNA and transbronchial biopsy do not.
    • Example proper coding: TBNA, TBBx, and Endobronchial biopsy- 31629 (TBNA), 31628 (TBBx), and 31625-59 (Endobronchial biopsy with modifier)
cci edits and mutually exclusive codes
CCI edits and mutually exclusive codes
  • Source for info:
    • www.cms.hhs.gov/physicians/cciedits
    • Click on NCCI overview, choose NCCI Edits – Physicians (on left side of page)
    • Choose the link:
      • Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems with a code range of 30000-39999
      • Updated quarterly (Jan, April, July , October)
cci group edits
CCI Group Edits

Endobronchial Bx needs modifier with TBNA or Transbronchial Bx

Never bill 31622 with any other code- it is the base Code, so always bundled

Allowed but would need modifier -59 and documentation:

Example: separate site (Bronchial stent on left and dilation on right)

modifiers example with two bronchoscopies same day
Modifiers- Example with two bronchoscopies same day
  • Patient is in the ICU, has a bronch for total lung atelectasis. Does well but that evening has lobar collapse, requiring a second bronch for therapeutic aspiration
    • 31645 for 1st therapeutic bronchoscopy
    • 31646-59 for 2nd bronchoscopy (note modifier)
    • Example of the multiple endoscopy rule
mutually exclusive edits
Mutually Exclusive Edits

Allowed but need modifier -59

multiple bronchoscopies same day
Multiple Bronchoscopies Same Day
  • You do a laser, stent the trachea. Several hours later in recovery the patient develops hemoptysis and is re-intubated. You do a bronch to evaluate the source. There is no active bleeding, everything looks good.
    • 31641 (laser)
    • 31631 (tracheal stent)
    • The 2nd bronch cannot be billed if all you did was look (31622 is bundled with all other codes)
multiple bronchoscopies same day23
Multiple Bronchoscopies Same Day
  • You do a laser, stent the trachea. Several hours later in recovery the patient develops hemoptysis and is re-intubated. You do a bronch to evaluate the source. There is old blood, you do therapeutic aspiration, and everything looks good.
    • 31641 (laser)
    • 31631 (tracheal stent)
    • 31645 for the 2nd bronch- it can be billed
    • KEY: DOCUMENTATION
modifier 51
Modifier -51
  • Do not use unless:
    • Check with your local Medicare carrier
    • Other 3rd party payor instruction
evaluation and management
Evaluation and Management
  • Patients can have an E & M bill in addition to bronchoscopy
  • E & M must use modifier -25 for a distinct problem
    • E&M should have a different Dx (ICD-9) than the bronchoscopy
example of e m modifiers
Example of E & M Modifiers
  • You see a patient with COPD and a lung mass with mediastinal adenopathy. You do bronchoscopy, TBNA, EBUS, Transbronchial biopsy, endobronchial biopsy and write a note on management of COPD.
  • Bronchoscopy:
    • TBNA (31629)
    • EBUS (31620)
    • TBBx (31628)
    • Endobronchial Bx (31625-59)
    • Diagnosis code (one for all of the above)- 785.6 mediastinal lymphadenopathy)
  • Progress Note E & M: 99232, Diagnosis code 496 (COPD)
cpt zzz codes
CPT ZZZ codes
  • ZZZ codes- “add-on codes”
    • Cannot stand alone- must be with another code.
  • ZZZ codes for bronchoscopy-
    • 31620: EBUS (must also use 31622-31646)
    • 31632: TBBx each additional lobe (must also use 31628)
    • 31633: TBNA each additional lobe (must also use TBNA 31629)
    • 31637: each additional major bronchus stent (must also use 31636)
    • 96570: PDT for ablation of tissue first 30 minutes (must also use 31641)
    • 96571: PDT each additional 15 minutes (must also use 96570 and 31641)
example add on codes ebus tbna
Example Add-on Codes: EBUS & TBNA
  • You do a bronch, TBNA with EBUS of the subcarinal lymph node and the right paratracheal lymph node using EBUS.
    • 31629 (TBNA of subcarinal node)
    • 31620 (EBUS)
    • 31633 (TBNA of each additional lobe)
example add on codes bronchial stent
Example- Add-on codes(Bronchial stent)
  • You do a bronch with laser followed by dilation and stenting of the trachea and dilation and stenting of the right and left mainstem bronchus for lung cancer.
  • 31641 (Laser)
  • 31631 (tracheal stent- note dilation is bundled)
  • 31636 (1st stent- note dilation is bundled)
  • 31637 (2nd stent- add on code)
summary
SUMMARY
  • Billing Impacts on Everything
    • Strategic Vision
    • Procedures & Equipment
    • Bronchoscopy Personnel
    • Support Personnel
    • Information Infrastructure
    • Financial Cycle
    • Integrating New Technologies