Flexible Bronchoscopy with Biopsy / BAL / EBUS
[Lung mass / mediastinal lymphadenopathy / hemoptysis / post-transplant surveillance / pulmonary infiltrate requiring BAL]
Same
Flexible bronchoscopy with [endobronchial biopsy / BAL / EBUS-guided TBNA of station X lymph nodes / transbronchial biopsy]
[***, MD/DO]
[Nurse/RT name]
Moderate sedation [/ MAC / general endotracheal] with topical 4% lidocaine
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.
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.]
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.
None
BAL fluid: [cytology, culture]
Endobronchial biopsies from [location]: pathology
EBUS-TBNA station [X]: cytology [and cell block]
Minimal
None
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
.TODAYVariants
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. The British Thoracic Society (BTS) guideline ceiling is 8.2 mg/kg in healthy adults; the ceiling drops to 5 mg/kg in hepatic or significant cardiac disease (reduced first-pass metabolism). Document the total dose administered and confirm it was below the applicable threshold. Patients with hepatic disease require explicit dose reduction documentation.
- 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. Rates are higher in fibrotic lung disease. A post-procedure CXR is mandatory and must be documented.
Documentation & Reimbursement Considerations
- Report Flexible Bronchoscopy with Biopsy / BAL / EBUS as the primary service when it is the definitive operation performed.
- Site determines the code.
- The ATS has an explicit compliance alert on this distinction.
- Document each lobe sampled separately.
- The related service is diagnostic bronchoscopy with small-volume cell washing (separate procedure, bundled when any intervention is performed). Bill the highest-complexity code when multiple techniques are used; brushing and washing performed alongside biopsy are bundled.
- Global period is 0 days (endoscopic). No post-procedure global applies; same-day complications requiring separate procedures can be billed independently.
- Fluoroscopic guidance is already accounted for under the bronchoscopy codes and should not be billed separately.
- 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.