BAL 1Q 2017 Coding Clinic Correction Notice

fishdl@shands.ufl.edu

The 1Q 2017 Coding Clinic printed a correction notice for previous advice from the 1Q 2016 Coding Clinic regarding the code for bronchoalveolar lavage (BAL). Coding Clinic's previous advice was to code BAL to drainage of the bronchus.  The 1Q 2017 correction states that a BAL should now be coded to drainage of the lung.  BAL of the lung is an OR procedure and has the potential to change the DRG to a surgical DRG (when sepsis or respiratory conditions are the pdx).  This is reminiscent of the arterial line insertion conundrum discussed a year ago.  Thoughts?

Thanks,

Donna Fisher

morris-jeff@CooperHealth.edu

Really??? I must admit I didn't pay close attention to this one. Interested to hear others thoughts. Sounds like we are back at square one.

lprescott1

This sort of makes sense though. In most cases we are performing lavage at the aveolar level- which is the lung tissue. The coding clinic reinforces this- "The lung body part values more accurately capture the objective of bronchoalveolar lavage, and coding to the lung is consistent with the general PCS convention of coding treatment of a tubular body part to the furthest anatomical site reached. In this case it is alveolar (lung) tissue." 

This is consistent with bronchoscopy with biopsy- if we obtain a biopsy of lung tissue this leads to a surgical DRG as well. 

 

slompashirt1

In most of our ICU bedside bronscopies with a BAL, the objective is NOT to obtain alveolar tissue for study, the objective is a small volume lavage to capture some fluid for culture and sensitivity to identify a suspected bacterial infection. 

cseluke

Is alveolar tissue lung or bronchial tissue? To obtain lung tissue, doesn't the operator of the scope have to puncture the alveolus, e.g., with a Wang needle? I find this very confusing. 

lostwater

Think of the intent of the procedure, cseluke.  Much of the time they are introducing fluid (and then removing) to loosen the gunk for a good diagnostic sample, culture, etc.  When you introduce the fluid, how deep (furthest) does it go?  In this case, the Coding Clinic recognized their earlier error because it would be difficult (impossible?) to lavage a lobe without the fluid getting into the alveolar tissue, thus the body part of the procedure is lung tissue.  Any lung tissue (shed cells) brought up is from washing, not a physical puncture (biopsy) as the Wang needle would do


Mark

slompashirt1

So with the logic of coding to the deepest level that Thelma age fluid would go, there would never be a situation to use the site of bronchus with a BAL or any lavage procedure. 
Another issue I worry about is that since this is becoming a valid OR procedure, some physicians that only do bronch with BAL may be coded with an OR procedure that is considered out of their scope of practice. (e.g. anesthesiologists who work as intensivists in ICUs).
any thoughts on this???

rwillcutt

Thanks to the guideline, the BAL is a valid OR procedure but not all of the time.  For instance, to move DRG 3 to DRG 4, the BAL has to be therapeutic, not diagnostic.  As Mark said, most of the time they are introducing fluid to loosen up the gunk to get a good sampling for cytology or culture--not actually trying to remove the gunk therapeutically.    

jjmaine@gmail.com

I agree in coding what the physician's intent was. Is this diagnostic or therapeutic? Doing the BAL to clear out bronchial passages is usually documented by the physician. Follow that up with brushings where the intent is to retrieve cells from the lung that cross the alveoli would support the surgical DRG vs procedural. Each case reviewed should stand on it's own.