How To Use CPT Code 31623

CPT 31623 describes a specific endoscopy procedure performed on the trachea and bronchi. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31623?

CPT 31623 is a code used to describe a specific endoscopy procedure performed on the trachea and bronchi. This procedure involves the use of a rigid or flexible bronchoscope to perform brushing or protected brushing. The provider may also use fluoroscopic guidance during the procedure.

2. Official Description

The official description of CPT code 31623 is: ‘Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushings.’

3. Procedure

1. During the procedure, the provider inserts a rigid or flexible bronchoscope through the nose or mouth and advances it down into the throat.
2. The provider then moves the scope to the bronchus, the main passageway to the lung, to examine the mucus lining or covering of the airways.
3. Brushing or protected brushing is performed using a soft brush. The provider introduces the brush through the tube of the scope and gently wipes the lung tissue or abrades a lung lesion.
4. The provider collects samples or specimens using the brush and sends them to the lab for further investigation.
5. Fluoroscopic guidance may be used during the procedure to provide live X-ray images for better visualization of body structures and instruments.
6. Once the procedure is complete, the provider removes the bronchoscope.

4. Qualifying circumstances

CPT 31623 is typically performed on patients who require examination of the trachea and bronchi. The procedure is used to collect samples or specimens for further investigation. It is important to note that this code specifically refers to brushing or protected brushing during the bronchoscopy procedure.

5. When to use CPT code 31623

CPT code 31623 should be used when a provider performs a bronchoscopy procedure with brushing or protected brushing. This code accurately describes the specific procedure and distinguishes it from other bronchoscopy procedures that may not involve brushing or protected brushing.

6. Documentation requirements

To support a claim for CPT 31623, the provider must document the following information:

• Patient’s medical history and reason for the bronchoscopy procedure
• Details of the procedure, including the use of a rigid or flexible bronchoscope, fluoroscopic guidance, and brushing or protected brushing
• Date and duration of the procedure
• Findings during the procedure, including any abnormalities observed
• Specimens collected and sent for further investigation
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 31623, ensure that the procedure performed includes brushing or protected brushing during a bronchoscopy with fluoroscopic guidance. It is important to follow the specific documentation requirements and guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 31623 has undergone several changes since its addition to the Current Procedural Terminology system. These changes include updates to the code description and the addition of fluoroscopic guidance as a component of the procedure.

9. Examples

1. A pulmonologist performing a bronchoscopy with brushing to collect samples for further investigation in a patient with suspected lung cancer.
2. An interventional radiologist using a flexible bronchoscope with protected brushing to obtain specimens from a patient with a suspected infection in the airways.
3. A thoracic surgeon performing a bronchoscopy with brushing to evaluate a patient with chronic cough and abnormal chest X-ray findings.
4. An otolaryngologist using a rigid bronchoscope with brushing to assess a patient with a foreign body lodged in the trachea.
5. An oncologist performing a bronchoscopy with protected brushing to collect samples for genetic testing in a patient with a family history of lung cancer.
6. A pulmonologist using a flexible bronchoscope with brushing to obtain samples from a patient with suspected tuberculosis.
7. An interventional radiologist performing a bronchoscopy with protected brushing to collect specimens from a patient with suspected fungal infection in the airways.
8. A thoracic surgeon using a rigid bronchoscope with brushing to evaluate a patient with recurrent pneumonia and suspected bronchial obstruction.
9. An otolaryngologist performing a bronchoscopy with brushing to assess a patient with chronic hoarseness and suspected vocal cord dysfunction.
10. An oncologist using a flexible bronchoscope with protected brushing to collect samples for molecular testing in a patient with advanced lung cancer.