ICD-10 coding challenge: Bronchoscopy and thoracoscopy

January 6th, 2017 / By Sue Belley, RHIA

Julia Palmer, project manager with the consulting services business of 3M Health Information Systems, is author of this month’s coding challenge blog.

Assign ICD-10 diagnosis code(s) and PCS procedure codes based on the following operative report:

Indications:

67-year-old male with RLL bronchiectasis and recurrent pneumonia

Procedure Details:

The patient was brought to the operating room and general anesthesia was smoothly induced. Flexible bronchoscopy was performed and showed no intrabronchial lesions, no mucous. The patient was repositioned in the decubitus position with all bony prominences appropriately padded. The patient was prepped and draped in the usual sterile fashion.

Three trocars were placed in the seventh intercostal space in the posterior axillary line, fifth intercostal space on the mid axillary line and posteriorly below the tip of the scapula.  The chest was inspected. Inferior pulmonary ligament was divided. Superior pulmonary vein and middle lobe vein were identified. Inferior pulmonary vein was circumferentially dissected and divided with a linear cutting stapler. Pulmonary arterial branches to the lower lobe were identified within the fissure, circumferentially dissected and divided with a linear cutting stapler. Division of the lung parenchyma was completed with the linear cutting stapler along the fissure. Bronchus was divided with the linear cutting stapler after adequate test insufflation of the lung.

Specimen was removed in the endoscopic retrieval bag. Absence of bronchial stump leak was assured under the water level insufflating the lung. Hemostasis was assured.

A 32-French chest tube was placed and secured to skin with suture. Port sites were closed in layers with interrupted Vicryl and 4-0 Monocryl to skin. Surgical glue and dressings were applied. The patient tolerated the procedure well and was taken to recovery in stable condition. 

ANSWER

J479                      Bronchiectasis, uncomplicated

Z8701                   Personal history of pneumonia (recurrent)

0BTF4ZZ                Resection of Right Lower Lung Lobe, Percutaneous Endoscopic Approach

0BJ08ZZ                Inspection of Tracheobroncial Tree, Via Natural or Artificial Opening Endoscopic (bronchoscopy)

BLOG

Assign J470 for bronchiectasis. It is unlikely this patient would have been taken to surgery with current pneumonia and more likely that the physician is indicating a history of recurrent pneumonia. We recommend a review of the entire record to determine pneumonia status and/or query the physician before final coding of the pneumonia diagnosis.

For the procedures, documentation is not as clear as it could be for the resection of the right lower lobe; however, the physician did document “Pulmonary arterial branches to the lower lobe were identified within the fissure, circumferentially dissected and divided with a linear cutting stapler. Division of the lung parenchyma was completed with the linear cutting stapler along the fissure.” Additionally, the diagnosis is documented in terms of the right lower lobe. Further documentation was available for this case which was not provided in the scenario but clearly indicated the right lower lobe was entirely resected. As always, when in doubt regarding details needed for accurate coding, query the physician.

The bronchoscopy is coded in addition to the thoracoscopic lobectomy based on the following PCS coding guideline, B3.11c:

“When both an Inspection procedure and another procedure are performed on the same body part during the same episode, if the Inspection procedure is performed using a different approach than the other procedure, the Inspection procedure is coded separately.” Since the bronchoscopy was performed via the natural approach, i.e., through the mouth, and the thoracoscopic lobectomy was performed via the percutaneous approach, both procedures are coded.

Please also note according to PCS guideline B6.1b:

“Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices.” Consequently, the chest tube inserted for postoperative drainage is not coded separately.

Julia Palmer is a project manager with the consulting services business of 3M Health Information Systems.