Flexible Bronchoscopy with Biopsy / BAL / EBUS

CPT 31622
Approach Endoscopic
Add-on / Variant CPTs
  • 31625 — Bronchoscopy with bronchial or endobronchial biopsy
  • 31628 — Bronchoscopy with transbronchial lung biopsy, single lobe
  • 31652 — Bronchoscopy with EBUS-guided intrathoracic LN aspiration
  • 31627 — Navigational bronchoscopy (electromagnetic navigation) — add-on
  • 31635 — Bronchoscopy with removal of foreign body
Preoperative Diagnosis:

[Lung mass / mediastinal lymphadenopathy / hemoptysis / post-transplant surveillance / pulmonary infiltrate requiring BAL]

Postoperative Diagnosis:

Same

Procedure Performed:

Flexible bronchoscopy with [endobronchial biopsy / BAL / EBUS-guided TBNA of station X lymph nodes / transbronchial biopsy]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/RT name]

Anesthesia:

Moderate sedation [/ MAC / general endotracheal] with topical 4% lidocaine

Indications:

The patient is a [age]-year-old [male/female] with [a right upper lobe mass / mediastinal adenopathy / hemoptysis / bilateral pulmonary infiltrates] requiring bronchoscopic evaluation and tissue diagnosis. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The vocal cords, trachea, carina, and bilateral bronchial trees were inspected to the subsegmental level. The mucosa was [normal / erythematous / edematous / with [endobronchial mass / mucosal irregularity] at [RUL / LUL / right main stem]]. The carina was [sharp / blunted / widened]. [EBUS: Station [4R / 7 / 11R] lymph nodes were identified and aspirated.] [BAL: [X] mL of saline instilled in the [RML / RLL] and [X] mL of turbid [/ bloody / purulent] fluid returned.]

Description of Procedure:

The patient was placed in the supine position. Supplemental oxygen [/ LMA / ETT] was established. Topical 4% lidocaine was applied to the oropharynx and instilled through the scope to the glottis, trachea, and bilateral mainstem bronchi [total lidocaine ≤8 mg/kg].

The flexible bronchoscope ([Olympus BF-XT160 / Pentax / Fujifilm]) was introduced [orally / through ETT / through LMA]. The vocal cords were inspected — [mobile and symmetric]. The trachea, carina, and bilateral bronchial trees were examined systematically to the subsegmental level.

[ENDOBRONCHIAL BIOPSY:]
An endobronchial [mass / lesion] was identified at [RUL / LUL]. [X] biopsies were taken with endobronchial forceps. Hemostasis was achieved with [epinephrine flush / cold saline / electrocautery] — bleeding was [minimal / controlled].

[BAL:]
The scope was wedged in the [RML / RLL / LLL] subsegment. [3 × 60] mL aliquots of normal saline were instilled and aspirated. Return was [X]% with [turbid / bloody / clear] appearance. Specimens sent for [cytology, culture, Gram stain, AFB, fungal culture, galactomannan, cell count].

[EBUS-TBNA:]
The EBUS bronchoscope was advanced. Under real-time ultrasound guidance, the [station 4R / 7 / 11R] lymph node was identified — [X × X] mm. A [22-gauge] aspiration needle was passed through the bronchial wall under direct ultrasound visualization. [X] passes were performed, yielding [adequate / bloody / scanty] material. On-site cytopathology confirmed [adequate cellularity / insufficient material requiring additional passes].

The scope was withdrawn. Total procedure time: [X] minutes. No significant bleeding or desaturation occurred.

Complications:

None

Specimens:

BAL fluid: [cytology, culture]
Endobronchial biopsies from [location]: pathology
EBUS-TBNA station [X]: cytology [and cell block]

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient tolerated the procedure well and was monitored for [1–2 hours]. [Post-procedure chest X-ray was obtained to rule out pneumothorax (transbronchial biopsy).] The patient was discharged when stable.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** — requiring bronchoscopic evaluation
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Flexible bronchoscopy with ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Moderate sedation/MAC + topical lidocaine

INDICATIONS: .PTAGE-year-old .PTSEX with ***. Tissue diagnosis/BAL required. Consent obtained.

FINDINGS: Cords mobile. Trachea/carina ***. Mucosa ***. [Endobronchial mass at ***.] [EBUS: Station *** node *** × *** mm.] [BAL: *** mL return, *** appearance.]

PROCEDURE:
Supine. O₂/LMA/ETT ***. Topical lido to glottis/trachea/mainstem. Scope *** introduced orally/ETT. Systematic inspection bilateral to subsegmental level. [Endobronchial biopsy: *** biopsies from ***, hemostasis ***.] [BAL: wedged ***, *** × *** mL instilled, *** % return.] [EBUS-TBNA: *** node station ***, *** × *** mm, *** passes with 22g needle, adequate cellularity.] Scope withdrawn. Procedure time *** min.

EBL: Minimal
SPECIMENS: As above
COMPLICATIONS: None
DISPOSITION: Monitored *** hours. [CXR: no pneumothorax.]

Signed: .ME, .MYDEGREE
.TODAY
Variants

Rigid Bronchoscopy (Hemoptysis / Airway Tumor)

For [massive hemoptysis / central endobronchial tumor causing airway obstruction], rigid bronchoscopy was performed under general anesthesia. The rigid bronchoscope ([8.5 / 9.5 mm]) was introduced orally with direct laryngoscopy assistance. Ventilation was maintained through the scope. [Hemostasis: the bleeding lobar orifice was identified. Epinephrine-soaked pledgets were applied. Argon plasma coagulation was used for hemostasis.] [Tumor debulking: the obstructing mass was cored out with the scope tip and forceps, re-establishing airway patency.] Rigid bronchoscopy is required when the airway must be controlled for bleeding, debulking, or stent placement.

Charting Tips
  • Document total topical lidocaine dose. Bronchoscopy-associated lidocaine toxicity is a real risk, particularly in patients with hepatic disease. Document the total dose administered (mg/kg) and confirm it was below the toxic threshold (8 mg/kg).
  • For EBUS-TBNA, document each station sampled by IASLC station number. 'Mediastinal sampling performed' is inadequate. Each station must be documented individually with the lymph node size and number of passes to confirm adequate N-stage sampling.
  • For transbronchial biopsy, document that post-procedure chest X-ray was obtained. Pneumothorax occurs in [2–5]% of transbronchial biopsies. A post-procedure CXR is mandatory and must be documented.
Billing Tips
  • 31625 (bronchoscopic biopsy with forceps, 3.03 wRVU) is the standard code for endobronchial or mucosal biopsy; 31628 (transbronchial lung biopsy, 3.46 wRVU) is for parenchymal sampling. Site determines the code.
  • 31629 (transbronchial needle aspiration TBNA, 3.66 wRVU) covers EBUS-guided or blind needle aspiration; add 31633 (+1.29 wRVU) for each additional lobe sampled by needle.
  • Add-on codes: 31632 (+1.00 wRVU) per additional lobe for transbronchial lung biopsy; 31633 (+1.29 wRVU) per additional lobe for needle biopsy. Document each lobe sampled separately.
  • BAL alone is 31622 (2.47 wRVU) or 31623 (brushing, 2.56 wRVU). Bill the highest complexity procedure performed; brush and wash performed with biopsy are bundled.
  • Global period is 0 days (endoscopic). No post-procedure global applies; same-day complications requiring separate procedures can be billed independently.
  • Fluoroscopy guidance (31656) or navigational bronchoscopy (31660/31661) are separately billable add-ons when performed. Document use in the operative note.
  • Document laterality, specific lobe(s) biopsied, number of samples per site, and type of sampling (forceps, needle, brush, BAL). Each separately billed element needs documentation.