How To Use CPT Code 31625

CPT 31625 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 31625?

CPT 31625 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 obtain one or more bronchial or endobronchial biopsies for the purpose of diagnosing lung disease. The provider may also use fluoroscopic guidance during the procedure.

2. Official Description

The official description of CPT code 31625 is: ‘Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites.’

3. Procedure

1. The provider prepares the patient for the procedure, ensuring they are appropriately prepped and anesthetized.
2. The provider inserts a rigid or flexible bronchoscope through the patient’s nose or mouth and advances it down into the throat.
3. The provider then moves the bronchoscope to the bronchus, the main passageway to the lung.
4. Using the bronchoscope, the provider examines the mucus lining or covering of the airways, looking for any abnormalities.
5. If necessary, the provider introduces an instrument, such as forceps, through the channel in the bronchoscope to obtain one or more biopsies from the bronchi.
6. The provider may take the biopsies from single or multiple sites within the bronchi.
7. The biopsies are sent for further investigation and analysis.
8. During the procedure, the provider may use fluoroscopic guidance, which involves live X-ray imaging to visualize body structures and instruments.
9. Once the procedure is complete, the provider removes the bronchoscope.

4. Qualifying circumstances

CPT 31625 is typically performed on patients who require a diagnostic evaluation of their lung condition. The procedure is used to obtain bronchial or endobronchial biopsies for further investigation and analysis. The provider must determine the medical necessity of the procedure based on the patient’s symptoms, medical history, and other relevant factors.

5. When to use CPT code 31625

CPT code 31625 should be used when a provider performs a bronchoscopy procedure with bronchial or endobronchial biopsy(s) using a rigid or flexible bronchoscope, and fluoroscopic guidance if necessary. This code is specifically for procedures involving single or multiple biopsy sites within the bronchi.

6. Documentation requirements

To support a claim for CPT 31625, the provider must document the following information:

• Reason for the procedure and the medical necessity of obtaining bronchial or endobronchial biopsies
• Type of bronchoscope used (rigid or flexible)
• Number and location of biopsy sites within the bronchi
• Use of fluoroscopic guidance, if applicable
• Date and duration of the procedure
• Any complications or adverse events that occurred during or after the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 31625, ensure that the procedure meets the specific criteria outlined in the code description. The use of a rigid or flexible bronchoscope, fluoroscopic guidance (if applicable), and the performance of bronchial or endobronchial biopsy(s) are all necessary components for reporting this code. It is important to follow the guidelines provided by the payer and submit any required supporting documentation with the claim.

8. Historical information

CPT 31625 has undergone several changes since its addition to the Current Procedural Terminology system. The code was first added on January 1, 1990. Since then, there have been multiple code changes, including updates to the code description and the addition of fluoroscopic guidance as an included component.

9. Examples

1. A pulmonologist performs a bronchoscopy with bronchial biopsy on a patient with suspected lung cancer.
2. A thoracic surgeon uses a flexible bronchoscope to obtain multiple endobronchial biopsies for a patient with unexplained respiratory symptoms.
3. An interventional radiologist performs a bronchoscopy with bronchial biopsy and fluoroscopic guidance to diagnose a patient with a suspected infection in the airways.
4. A respiratory therapist assists a pulmonologist in performing a bronchoscopy with multiple bronchial biopsies on a patient with a history of chronic obstructive pulmonary disease (COPD).
5. A pathologist analyzes the bronchial biopsies obtained during a bronchoscopy procedure to determine the presence of abnormal cells or tissue.
6. A patient undergoes a bronchoscopy with bronchial biopsy to investigate the cause of persistent cough and shortness of breath.
7. A bronchoscopy with bronchial biopsy is performed on a patient with suspected tuberculosis to obtain samples for laboratory testing.