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April 28, 2008

Coding for Lung Biopsy
For The Record
Vol. 20 No. 9 P. 29

A lung biopsy is a procedure during which a small amount of tissue from the lung is removed for examination under a microscope. The procedure helps to evaluate and diagnose a lung infection, lung cancer, or other lung diseases.

Types of Lung Biopsies
• Bronchoscopy with transbronchial biopsy (ICD-9-CM code 33.27). The bronchoscope is inserted through the nose and down the back of the throat into the trachea and bronchi. Forceps are passed through the bronchoscope and the bronchus into the lung alveoli. Typically, the patient is instructed to breathe out slowly as the physician obtains small samples of lung tissue. The forceps puncture the terminal bronchus, and samples of the peribronchial alveoli (lung tissue) are taken (AHA Coding Clinic for ICD-9-CM, 1992, fourth quarter, pages 27-28). This step is usually repeated multiple times until several samples are obtained. This is the procedure of choice, especially when sarcoidosis, lymphangitic carcinomatosis, eosinophilic pneumonia, Goodpasture’s syndrome, or infection is suspected.

• Bronchoscopy with closed biopsy of bronchus (33.24). A bronchoscope is inserted and tissue samples are collected by brushing or washing the bronchus. Code 33.24 also includes diagnostic bronchoalveolar lavage, washing out of the bronchioles and alveoli to collect cells for analysis. Brush biopsy of the lung is also included under code 33.24. Note that even though it states “lung,” the brush biopsy is of the bronchus, not the lung or alveolar tissue. This documentation should not be confused with a transbronchial lung biopsy (33.27).

If a bronchoscopy is performed and a biopsy is taken from both the bronchus and the lung during the same procedure, it would be appropriate to assign both 33.24 and 33.27 (AHA Coding Clinic for ICD-9-CM, 2004, third quarter, page 9).

Other types of lung biopsies include the following:

• Needle biopsy of lung (33.26) — classified as a closed biopsy of the lung, a small sample of lung tissue is removed through a slender hypodermic needle.

• Fine needle aspiration of lung (33.26) — classified as a closed biopsy of the lung.

• Transthoracic needle biopsy of lung (33.26) — classified as a closed biopsy of the lung.

• Percutaneous biopsy of lung (33.26) — classified as a closed biopsy of the lung.

• Thoracotomy with incisional/open biopsy of lung (33.28) — open biopsy involving an incision through the chest wall into the pleural space for the purpose of obtaining lung tissue.

• Exploratory thoracotomy with needle biopsy (34.02 + 33.26) — a needle biopsy is performed, along with exploration of the thorax.

• Thoracotomy with needle biopsy without exploration (33.26) — only a code for the closed biopsy is assigned.

• Thoracoscopic biopsy of lung (33.20) — a sample of lung tissue is removed through a thoracoscope. This is the procedure of choice for a solitary pulmonary nodule and to evaluate pulmonary disease (AHA Coding Clinic for ICD-9-CM, 2007, fourth quarter, pages 109-113). Procedures performed via a thoracoscopy are also documented as video-assisted thoracoscopic surgery, minimally invasive thoracic surgery, and thoracoscopic surgery.

As stated above, thoracoscopic wedge biopsy of the lung is classified to code 33.20. Thoracoscopic wedge resection of the lung is coded to 32.20. The code depends on the physician’s documentation and the procedure performed (wedge biopsy vs. wedge resection).

Prior to October 1, 2007, it was difficult to identify procedures done via a thoracoscopy. However, several new codes were created and made effective after this date to identify thoracoscopic procedures of the chest, such as the following:

• 32.20, Thoracoscopic excision of lesion or tissue of lung – thoracoscopic wedge resection;

• 32.30, Thoracoscopic segmental resection of lung;

• 32.41, Thoracoscopic lobectomy of lung;

• 32.50, Thoracoscopic pneumonectomy;

• 33.20, Thoracoscopic lung biopsy;

• 34.06, Thoracoscopic drainage of pleural cavity – evacuation of empyema;

• 34.20, Thoracoscopic pleural biopsy; and

• 34.52, Thoracoscopic decortications of lung.

Coding and sequencing for lung biopsy 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.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.