The Bronchoscopy Tubular Confusion

The Bronchoscopy Tubular Confusion


Many coding professionals, auditors, clinical documentation integrity (CDI) specialists, and healthcare professionals struggle with applying guidelines B4.1c and B3.2 in the ICD-10-PCS Official Guidelines for Coding and Reporting because they both describe multiple body parts. Confusion seems greatest when coding bronchoscopies and applying these guidelines.

According to the Centers for Medicare and Medicaid Services (CMS), tubular body parts are defined in ICD-10-PCS as “those hollow body parts that provide a route of passage for solids, liquids, or gases.” They include the cardiovascular system, and body parts such as those contained in the gastrointestinal tract, genitourinary tract, biliary tract, and respiratory tract.1 The issue seems to be in making a distinction between the application of guidelines B4.1c and B3.2b.

Guideline B4.1c directs code assignment of the body part value corresponding to the furthest anatomical site from the point of entry when a procedure is performed on a continuous section of a tubular body part. On the other hand, guideline B3.2b directs the code assignment of multiple procedures when the same root operation is repeated in multiple body parts, and those body parts have separate and distinct body parts classified to a single ICD-10-PCS body part value. Professionals should not overanalyze and misinterpret the meanings of each individual procedural coding guideline because this can cause confusion.

The key in helping to differentiate between these guidelines is in applying them based on the objective of the procedure being performed. Another important factor is determining the appropriate ICD-10-PCS root operation definitions that are relevant to tubular body parts. The ICD-10-PCS root operation groupings that are applicable to tubular body parts include:

  • Bypass—altering the route of passage of the contents of a tubular body part
  • Dilation—expanding the orifice or lumen of a tubular body part
  • Occlusion—completely closing off the orifice or lumen of a tubular body part
  • Restriction—partially closing off the orifice or lumen of a tubular body part

Guideline B4.1c would be applied to these root operations since the procedural objective refers to a tubular body part.

Other ICD-10-PCS root operations, such as excision, resection, destruction, and extraction are grouped into a procedural category that takes out some or all of a specified body part. Health information management (HIM) professionals should remember the procedural objective with this group of root operation involves cutting out or off, pulling out of or off, or eradicating without replacement all or some of a body part. Examples of procedures that match these procedural objectives are suction dilation and curettage, breast lumpectomies, endometrium fulguration, and total lobectomy of the right upper lobe of the lung. These procedures can be performed within the tubular body part as well but distinguishing the reason for the procedure will help reduce the confusion when applying these particular guidelines.

Additionally, root operations drainage, extirpation, and fragmentation are categorized as root operations that take out solids, liquids, or gases from a body part. These ICD-10-PCS root operations should be separately identifiable because the objective of these procedures involves taking out solids, fluids, or gases from within a specified body part.

Thrombectomies, bronchoalveolar lavages (BALs), and lithotripsies are just a couple of procedures that are categorized into these root operation groupings. Many coding, auditing, and CDI professionals get lost in the root operation forest and fail to focus on the objective of the procedure that is being performed. Remembering to determine the objective or reason the procedure is being performed will help HIM professionals to minimize getting lost in the root operation woods.
Furthermore, when you are coding bronchoalveolar lavage (BAL), coding experts should understand that a BAL involves washing out and sampling alveoli of the lung (also known as the air sacs) and is normally performed using a bronchoscopy.

The objective of this procedure is draining fluid from within the bronchus and typically involves removing fluid from the bronchus, which is coded to ICD-10-PCS root operation, drainage.2 Remember to meticulously review the details of the operative report and the pathology report to further pinpoint the type of specimen that was collected or removed. In addition, take caution when relying on the encoder to guide you through the coding pathway, because sometimes the incorrect selection can be made which could result in an incorrect procedure code assignment.

Lastly, there are a few important questions to consider when assigning ICD-10-PCS procedure codes. What was the objective of the procedure being performed? What body part was the procedure limited to, lung tissue or within the bronchus? Where was the procedure performed, on a specific lobe of the lung or within the bronchus? Always remember to query the provider in cases where the procedural objective or type of material examined is not clear within the documentation.

Lastly, do not confuse the multiple procedure coding guidelines with the most distal tubular body part guideline because they both have distinct procedural objectives. Assign the specific root operations that apply to a tubular body part and keep a separate distinction from the multiple procedures coding guidelines. The multiple procedures coding guidelines refer to multiple procedures being performed during the same operative session when performed on separate body parts, the same procedure performed on separate and distinct body parts distinctly identified by a single ICD-10-PCS body part value, and multiple distinct procedural objectives performed on the same body part.

  1. Averill, Richard F. et al. “Development of the ICD-10 Procedure Coding System.” Journal of AHIMA 69, no. 5 (1998): 65-72.
  2. American Hospital Association. AHA Coding Clinic ICD-9-CM, (Third Quarter 2002), 16-17.

Centers for Medicare and Medicaid Services. ICD-10-PCS, Official Coding Guidelines for Coding and Reporting 2020.

Centers for Medicare and Medicaid Services. ICD-10-PCS Reference Manual.


Tina Bruce ( is assistant professor at San Juan College.

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1 Comment

  1. Please give examples to show how coders are misapplying the guidelines and what the correct application is.

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