Bronchial alveolar lavage
Hi,
We are having a difficult time between the CDS and coding on how to code a BAL. I am including an excerpt from the procedure note. The CDS wants to code: 0B958ZZ and the coder coded 0B958ZX
Flexible fiberoptic bronchoscopy
Findings: Â
1. Bloody nasal passages (L) [ suspected from NGT]. Â
2. Copious moderately thick pale secretion in the hypopharynx/vocal cords. The VC did not seem to oppose (but patient sedated and may not have made effort). Ddx includes VC paralysis. Â
3. Copious moderately thick pale secretions in the trachea/carina and bilateral
Specimens:
1. BAL RML: routine microbiology, fungal
Estimated Blood Loss: 0 ml
Complications: None
Indications and History:
The risks, benefits, complications, treatment options and expected outcomes were discussed with the patient and his sister. The possibilities of reaction to medication, pulmonary aspiration, perforation of a viscus, bleeding, failure to diagnose a condition and creating a complication requiring transfusion or operation were discussed with the patient. Given his current condition, he was unable to personally sign the consent, so his sister did.
Description of Procedure:
Time out was take to confirm the patient's identity and procedure being performed. Â
Monitoring- continuous cardiopulmonary monitoring including pCO2 at the bedside in the CCU.
After the induction of topical nasopharyngeal anesthesia, the patient was positioned with HOB at 30% and the bronchoscope was passed through the L nares . The vocal cords were visualized and covered in pale yellow secretions. VC did not close, but patient did not appear to respond to requests to cough or say "eeee". The scope was passed through the VC easily and there was more secretions coating the carina, L and R main bronchi and distally. All these secretions were removed.
BAL was then obtained in the RML. Residual fluid was removed as well as secretions at this time and scope removed.
We are having a difficult time between the CDS and coding on how to code a BAL. I am including an excerpt from the procedure note. The CDS wants to code: 0B958ZZ and the coder coded 0B958ZX
Flexible fiberoptic bronchoscopy
Findings: Â
1. Bloody nasal passages (L) [ suspected from NGT]. Â
2. Copious moderately thick pale secretion in the hypopharynx/vocal cords. The VC did not seem to oppose (but patient sedated and may not have made effort). Ddx includes VC paralysis. Â
3. Copious moderately thick pale secretions in the trachea/carina and bilateral
Specimens:
1. BAL RML: routine microbiology, fungal
Estimated Blood Loss: 0 ml
Complications: None
Indications and History:
The risks, benefits, complications, treatment options and expected outcomes were discussed with the patient and his sister. The possibilities of reaction to medication, pulmonary aspiration, perforation of a viscus, bleeding, failure to diagnose a condition and creating a complication requiring transfusion or operation were discussed with the patient. Given his current condition, he was unable to personally sign the consent, so his sister did.
Description of Procedure:
Time out was take to confirm the patient's identity and procedure being performed. Â
Monitoring- continuous cardiopulmonary monitoring including pCO2 at the bedside in the CCU.
After the induction of topical nasopharyngeal anesthesia, the patient was positioned with HOB at 30% and the bronchoscope was passed through the L nares . The vocal cords were visualized and covered in pale yellow secretions. VC did not close, but patient did not appear to respond to requests to cough or say "eeee". The scope was passed through the VC easily and there was more secretions coating the carina, L and R main bronchi and distally. All these secretions were removed.
BAL was then obtained in the RML. Residual fluid was removed as well as secretions at this time and scope removed.