How To Use CPT Code 31628

CPT 31628 describes the procedure of obtaining transbronchial lung biopsies from a single lobe of the lung using a rigid or flexible bronchoscope, with or without fluoroscopic guidance. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31628?

CPT 31628 can be used to describe the procedure in which a healthcare provider uses a rigid or flexible bronchoscope to obtain one or more transbronchial biopsies from a single lobe of the lung. This code may also include the use of fluoroscopic guidance during the procedure.

2. Official Description

The official description of CPT code 31628 is: ‘Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe.’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. The provider inserts a rigid or flexible bronchoscope through the nose or mouth and advances it to the bronchus, the main passageway to the lung.
3. The provider examines the airways for any abnormalities and introduces an instrument, such as forceps, through the scope’s channel.
4. The provider takes one or more transbronchial biopsies of tissue from a single lobe of the lung.
5. If necessary, the provider may use fluoroscopic guidance to visualize the procedure on a monitor.
6. The provider removes the bronchoscope to complete the procedure.

4. Qualifying circumstances

CPT 31628 is performed on patients who require transbronchial lung biopsies from a single lobe of the lung. The procedure is typically used to investigate abnormalities or lesions in the lung tissue. The use of a rigid or flexible bronchoscope, as well as fluoroscopic guidance, may be necessary depending on the specific case.

5. When to use CPT code 31628

CPT code 31628 should be used when a healthcare provider performs transbronchial lung biopsies from a single lobe of the lung using a rigid or flexible bronchoscope, with or without fluoroscopic guidance. This code should be reported only once, regardless of the number of biopsies performed in the lobe.

6. Documentation requirements

To support a claim for CPT 31628, the healthcare provider must document the following information:

• Indication for the procedure and the need for transbronchial lung biopsies
• Type of bronchoscope used (rigid or flexible)
• Whether fluoroscopic guidance was utilized
• Date and duration of the procedure
• Number of transbronchial biopsies performed
• Location of the biopsies (single lobe)
• Any complications or additional findings during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31628, ensure that the procedure involves obtaining transbronchial lung biopsies from a single lobe of the lung using a rigid or flexible bronchoscope, with or without fluoroscopic guidance. There are no specific guidelines regarding reporting this code with other codes. However, it is important to follow any applicable payer guidelines and modifiers if necessary.

8. Historical information

CPT 31628 was added to the Current Procedural Terminology system on January 1, 1990. There have been several code changes since its addition, including updates to the description and inclusion of fluoroscopic guidance.

9. Examples

1. A pulmonologist performing a transbronchial lung biopsy from a single lobe of the lung using a flexible bronchoscope.
2. A thoracic surgeon obtaining transbronchial lung biopsies from a single lobe of the lung with the assistance of fluoroscopic guidance.
3. An interventional radiologist performing a transbronchial lung biopsy from a single lobe of the lung using a rigid bronchoscope.
4. A pulmonologist using a flexible bronchoscope to obtain multiple transbronchial lung biopsies from a single lobe of the lung.
5. A respiratory therapist assisting a pulmonologist in obtaining a transbronchial lung biopsy from a single lobe of the lung using a flexible bronchoscope.
6. A pulmonologist performing a transbronchial lung biopsy from a single lobe of the lung with the aid of fluoroscopic guidance.