Insight into operative notes clarifies how to code cryptic 'TBB'
by Robert S. Gold, MD
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it onto the official abbreviation list at their hospital. Some don’t. And even if they did, some physicians will use the wrong term. Take an example that was featured in the January Medicare Quarterly Provider Compliance Newsletter regarding proper identification and ICD-9-CM coding of a procedure that a pulmonologist performed. Specifically, the newsletter addressed auditors’ review of the inappropriate use of procedure code 33.27.
Consider the following procedures and their respective ICD-9-CM procedure codes:
- Bronchoscopy with biopsy (33.24) or TBB
- Bronchoscopic lung biopsy (33.27) or TBLB
As many of you know, the future holds a new way of evaluating operative reports in order to assign appropriate ICD-10-PCS codes. The mainstay of this technique involves reading the operative report so that you can assign codes based on what the physician did. Gone are the days when you will easily find one procedure code for an operation by just looking at what the surgeon said he did.
A bronchoscopy employs a technique whereby a physician sedates a patient and uses topical anesthesia to numb the patient’s mouth, tongue, throat, and vocal cords (or performs the procedure on a patient who either has a tracheostomy in place or is under general anesthesia). It is usually a diagnostic procedure to try to identify whether the patient has something obstructing the airway or is bleeding from the respiratory tract or has some sort of process going on which impairs breathing.
The goal is to look down the trachea to see the mainstem bronchi to the right and left lung, then to go farther into the tubes to look at the two lobar bronchi on the left and the three on the right, and maybe to look down as far as possible via these bronchi into the segmental bronchi of the lungs. Depending on the circumstances, the physician may then do one of the following:
- Grasp a foreign body with a forceps and remove it
- Aspirate a mucus plug or blood clot
- Sample pus and send it to the microbiology lab or sample cells for cytologic evaluation
- Biopsy with a biopsy forceps any growth on the wall of the bronchi or irritation or any visible abnormality
So the main elements of virtually every bronchoscopic procedure is:
- Visualization of the tubes (the bronchoscopy)
- Washings (insertion of saline solution into the segmental orifices and sucking it out for microbiologic or microscopic examination of cells retrieved with the saline)
- Brushings (using a device that sort of looks like a pipe cleaner that can be inserted into bronchial segments that are too small for the scope to get into and trying to scrub off some cells for histologic examination)
- Biopsy of a lesion on the wall of the bronchus or area of irritation that the endoscopist can see.
That’s procedure code 33.24.
Sometimes a diagnostic bronchoscopy may turn into a therapeutic one as in the case of finding a mucus plug that explains the presence of atelectasis, and then removing that plug. Sometimes it starts as a therapeutic bronchoscopy for patients with cystic fibrosis who come in periodically to get their bronchi sucked out and irrigated so that they can go back to school a lot more comfortable than before the cleaning.
Once in a while a physician will see a patient who has a chest x-ray indicating a mass in the lung tissue, but the character of this mass is unknown. Obviously, the most important matter is to evaluate whether it represents cancer, and, if so, whether it is a primary lung cancer or one that has metastasized to the lung from another organ.
If the mass is near the center of the chest, near the heart, and near the main spit of the trachea, a physician can likely evaluate it with a regular diagnostic bronchoscopy.
However, if the lesion is peripheral—a “coin” lesion, near the chest wall and not near the center of the chest—there’s no way that a physician can see it with a bronchoscopy; the bronchial tubes are just too small for a scope to reach. And remember, the endoscopist has to see the lesion if he’s performing a bronchoscopy with biopsy.
In the case of peripheral coin lesions, there are several approaches a physician can take to identify the mass. He or she can do a percutaneous lung biopsy. That’s not a problem; using radiographic control, the physician inserts a needle through the chest wall toward and, hopefully, into the lesion and takes a “bite” of it (ICD-9-CM procedure code 33.26).
Then there’s the possibility of doing a thoracoscopic procedure in the OR, whereby the physician puts a larger tube into the patient’s chest through a skin incision. The physician then determines whether he or she can see the lesion from the surface of the lung, and, if so, biopsies it (ICD-9-CM procedure code 33.20).
There’s also always the option for the physician to perform a formal thoracotomy, doing the diagnosis and treatment at one fell swoop (ICD-9-CM procedure code 33.25 if biopsy of bronchus; code 33.28 if biopsy of lung).
But physicians are recognizing that some of these masses don’t need to be removed, and in other cases, some patients who are unable to undergo a formal thoracotomy might respond to treatment after diagnosis with a lesser procedure.
So if the patient has a coin lesion, the physician may perform a transbronchoscopic lung biopsy (TBLB). Preparing the patient the same way as for the routine bronchoscopy, the physician inserts the bronchoscope and, using x-ray guidance, advances as far as possible into the appropriate bronchus that will aim at the lesion seen on the x-ray. Then they tell the patient to hold their breath and jam a biopsy forceps though the wall of the bronchus and into the lesion and take a bite of it. They repeat this until they have a few pieces of tissue that they can turn into the pathologist to see whether they were able to get a sample of the lesion. That’s procedure code 33.27.
Well, there’s a caveat. Sometimes, while doing a regular diagnostic bronchoscopy, a physician ascertains that there is something pushing against the wall of one of the bronchus from the outside, but he or she can’t actually see it—just an impression of its effect. This may be an area of narrowing with normal looking mucosa over it, and maybe the endoscopist can’t even get by the narrowed area. Or, looking down the scope, rather than seeing a sharp cut-off where two or more bronchi are supposed to extend from, the physician may see considerable blunting of the carina (i.e., the split) and know that there’s something outside the bronchus causing that blunted appearance. In this case, it could be a lymph node, a mediastinal tumor of some sort, a lung cancer, or an abscess. They physician won’t often know until he or she bites into it. Again, the endoscopist pushes the biopsy forceps through the wall of the bronchus into the unseen mass to take samples. This is transbronchoscopic, as well. If it’s a needle biopsy of the lung, it’s procedure code 33.26 just as the percutaneous approach above.
Basically, to code correctly for these procedures, coders should read what the physician did to code for these procedures. They should not rely on what the physician said he or she did.
Editor's note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician clinical documentation improvement programs. E-mail questions to him at rgold@DCBAInc.com.