How To Use CPT Code 31629

CPT 31629 describes the procedure of obtaining biopsies from the trachea, main stem, and/or lobar bronchus using a transbronchial needle aspiration technique. 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 31629?

CPT 31629 is used to describe the diagnostic procedure in which a healthcare provider uses a bronchoscope to obtain one or more biopsies from the trachea, main stem, and/or lobar bronchus. This is done using a transbronchial needle aspiration technique, which involves inserting a needle through the bronchoscope to collect tissue samples for further investigation.

2. Official Description

The official description of CPT code 31629 is: ‘Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i).’ It is important to note that this code should only be reported once for upper airway biopsies, regardless of the number of transbronchial needle aspiration biopsies performed in the upper airway or in a lobe. To report biopsies performed on additional lobes, use CPT code 31633.

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. The provider inserts a bronchoscope through the nose or mouth and advances it into the throat.
3. The provider examines the mucus lining or covering of the airways for any abnormalities.
4. A needle is introduced through the channel in the bronchoscope, and the provider performs a transbronchial needle aspiration biopsy of tissue from the trachea, main stem, and/or lobar bronchus.
5. The provider may take single or multiple biopsies and sends them for further investigation.
6. Fluoroscopic guidance may be used during the procedure to assist the provider in visualizing body structures and instruments.
7. Once the biopsies are obtained, the provider removes the bronchoscope to complete the procedure.

4. Qualifying circumstances

CPT 31629 is performed on patients who require diagnostic biopsies from the trachea, main stem, and/or lobar bronchus. This procedure is typically done to investigate abnormalities or suspected diseases in the airways. It is important to note that this code should only be reported once for upper airway biopsies, regardless of the number of transbronchial needle aspiration biopsies performed in the upper airway or in a lobe.

5. When to use CPT code 31629

CPT code 31629 should be used when a healthcare provider performs a bronchoscopy with transbronchial needle aspiration biopsies on the trachea, main stem, and/or lobar bronchus. This code should not be used for biopsies performed on additional lobes, as a separate code (31633) should be used for that purpose.

6. Documentation requirements

To support a claim for CPT 31629, the healthcare provider must document the following information:

• Patient’s diagnosis or reason for the procedure
• Specific details of the biopsies performed, including the location (trachea, main stem, and/or lobar bronchus)
• Use of fluoroscopic guidance, if applicable
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 31629, ensure that the procedure meets the criteria outlined in the official description. It is important to note that this code should only be reported once for upper airway biopsies, regardless of the number of transbronchial needle aspiration biopsies performed in the upper airway or in a lobe. Use additional codes, such as CPT code 31633, for biopsies performed on additional lobes. Follow any specific guidelines provided by the payer or coding guidelines for accurate billing.

8. Historical information

CPT 31629 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been several historical changes to the code, including updates to the official description and the addition of related codes.

9. Examples

1. A pulmonologist performing a bronchoscopy with transbronchial needle aspiration biopsies on the trachea and main stem of a patient with suspected lung cancer.
2. A thoracic surgeon obtaining biopsies from the trachea and lobar bronchus using a transbronchial needle aspiration technique during a bronchoscopy procedure.
3. An interventional radiologist performing a bronchoscopy with transbronchial needle aspiration biopsies on the trachea and main stem to investigate a patient’s persistent cough.