AHA Coding Clinic® for HCPCS - 2022 Issue 1; Ask the Editor

Bronchoscopy for treatment of tracheal stenosis

A patient with tracheal stenosis presented for treatment using flexible video bronchoscopy with radial electrocautery knife incision and balloon dilation. The video bronchoscope was inserted and 3 cm below the vocal cords, web-like stenosis obstructing the airway was noted. Therefore, a decision was made to dilate the airway starting with radial incisions made with an electrocautery needle-knife at the 3, 12, and 9 o’clock positions. Next, the trachea was dilated up to 15 mm for 60 seconds followed by another dilation up to 16.5 mm for 40 seconds. Following dilation, the airway had expanded to approximately 95% of normal diameter. What is the correct code assignment for electrocautery knife incisions and balloon dilation for treatment of tracheal stenosis? Is it appropriate to report CPT code 31630, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial dilation or closed reduction of fracture, to capture the dilation, or code 31641, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy), to capture the incisions made with electrocautery, or both codes? ...

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