The 2004 revisions to the CPT codebook will impact billing for several specialties, notably ENT, GI and ocuplastic surgeries. This month, I'll guide you through managing the respiratory and digestive system coding changes. Next time, we'll look at ophthalmology.

Revised bronchoscopy codes
Perhaps even more than knowing when to use new codes, coders often have problems adjusting to changes in the descriptions of existing codes. The 2004 updates include several coding language changes that directly impact the conditions under which your billing staff may and may not use these codes.

Let's look first at the revised bronchoscopy codes. Possible biopsy sites for a bronchoscopic biopsy include the upper airway (which extends from the vocal cords to the lobar bronchi) and each of the five lobes of the lungs and their bronchi: the right upper, middle and lower lobes, and the left upper and lower lobes. There are three distinctly different types of biopsies performed via flexible or rigid bronchoscopy: bronchial, endobronchial and transbronchial. Make sure the medical record specifies the type of biopsy as well as the procedure itself. Here are some examples:

• 31622. This diagnostic code previously specified that the procedure must be performed under fluoroscopic guidance. This is no longer the case. The code may also be used regardless of whether the endoscopist performed cell washing. If he did both cell washing and the diagnostic bronchoscopy, you may bill cell washing as a separate procedure.
• 31625. This code's description has undergone several important revisions. The code may now be used for either bronchial or endobronchial biopsies of single or multiple sites, with or without fluoroscopic guidance. An important tip: If the physician takes a bronchial mucosal biopsy under direct visualization, the medical record should also specify this. Additionally, the code's "single or multiple sites" wording means you can only bill this procedure once even if the surgeon biopsies different anatomic sites.
• 31628. This code for transbronchial lung biopsies contains added language specifying single-lobe biopsies. Although the code no longer requires fluoroscopy, surgeons typically perform these peripheral biopsies with fluoroscopic guidance of the biopsy forceps. Importantly, when taken from different lobes, the additional biopsies represent separate billable procedures; a new CPT code, 31632, now exists to bill for each additional lobe.
• 31629. The revised code now reads, "transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus [bronchi]" and no longer requires fluoroscopy. This code represents a less invasive technique that otherwise would require an open surgical approach. In a transbronchial needle aspiration, the surgeon uses a specially-designed biopsy needle and takes the biopsy centrally via penetration of a large airway and aspiration of a lymph node or central mass lesion. The 2004 codebook includes 31633 to bill for additional lobes.

As always, make certain that the medical record submitted in support of the claim thoroughly documents the procedure. This is especially crucial when you tie the procedure to multiple CPT codes. Again, let's look at bronchoscopy. Make sure the medical record documents these three things:

• the type of bronchoscopy (diagnostic or therapeutic)
• the laterality (unilateral or bilateral) of each therapeutic procedure performed; and
• the details of each therapeutic procedure. For biopsies, specify each biopsy type and the lobe. Common billable procedures accompanying bronchoscopy include brushing/protected brushing, bronchial alveolar lavage (BAL), dilation (tracheal or bronchial), closed fracture reduction, tracheal stent placement, tumor excisions and stenosis relief using techniques other than excision (such as laser therapy or cryotherapy).

Digesting the 2004 GI updates
The 2004 CPT codebook includes new and revised GI endoscopy codes that let facilities report procedures based on the level of advancement of the echoendoscope. In some cases, you can use the new GI codes only under highly specific conditions. In others, they may open additional reimbursement possibilities. One new upper GI endoscopy code, 43237, may be used, as appropriate for endoscopy of the esophagus, stomach and either the duodenum and/or jejunum. For endoscopic ultrasound examination, the use of this code is limited to the esophagus. A second, 43238, is a bit more complex, requiring endoscopy of one or more of the aforementioned sites, in conjunction with "transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s) of the esophagus."

Conversely, a revised code, 43259, now includes endoscopic ultrasound examination of the esophagus, stomach and either the duodenum and/or jejunum. Another revised code, 43242, specifies "transendoscopic ultrasound-guided" or "intramural or transmural" fine needle aspiration or biopsy of one or more of these sites.

The 2004 GI endoscopy CPT codes contain many subtle descriptive differences that affect when you can use specific codes and whether other codes may also be used for additional reimbursement. The physician must document the following clinical information in the medical record when doing GI endoscopy:

• each site examined with the scope (such as the esophagus, stomach, descending colon, transverse colon, small intestine)
• whether the physician performed an endoscopic ultrasound examination (if so, document each anatomic site examined with the echoendoscope)
• whether the surgeon performed transendoscopic of a catheter, an intraluminal tube and/or a stent (including predilation)
• the type of surgical procedure performed on each lesion, polyp, tumor and/or cyst, including specimen biopsy, bipolar electrosurgical removal, monopolar destruction/ablation/fulguration, snare technique removal, and/or submucosal injection (such as India ink, saline, corticosteroids, Botox) and
• the type of biopsy performed on each lesion, including partial or total, cold or hot biopsy forceps removal and transendoscopic ultrasound-guided intramural fine needle aspiration/biopsy.