31628

Bronchoscopy, rigid or flexible, with bronchial alveolar lavage (BAL)

A diagnostic procedure involving the insertion of a rigid or flexible bronchoscope into the tracheobronchial tree to visualize the airways. During the procedure, bronchoalveolar lavage (BAL) is performed by instilling sterile saline solution into a specific segment of the lung and then aspirating the fluid. The collected fluid contains cells and other substances from the alveoli and bronchioles, which are subsequently sent for various laboratory analyses (e.g., cytology, microbiology, immunology) to aid in the diagnosis of diffuse lung diseases, infections, or malignancies. This procedure is typically performed under conscious sedation or general anesthesia.

Clinical Indications

  • Diagnosis and evaluation of diffuse parenchymal lung diseases (e.g., interstitial lung disease, sarcoidosis, hypersensitivity pneumonitis, pulmonary alveolar proteinosis).
  • Investigation of suspected pulmonary infections (bacterial, viral, fungal, mycobacterial, parasitic) in immunocompromised patients or when less invasive methods fail.
  • Evaluation of unexplained persistent cough or hemoptysis when other diagnostic modalities are inconclusive.
  • Detection of malignant cells in suspected lung cancer, especially for diffuse involvement or when other biopsy techniques are not feasible.
  • Assessment of lung transplant rejection or opportunistic infections in transplant recipients.
  • Monitoring disease activity or response to treatment in certain inflammatory lung conditions.

Procedure Steps

  1. Patient preparation, including informed consent, administration of local anesthesia to the upper airway, and intravenous sedation or general anesthesia.
  2. Insertion of the bronchoscope (flexible or rigid) through the mouth or nose, carefully advancing it past the vocal cords into the trachea and main bronchi.
  3. Systematic visualization and inspection of the tracheobronchial tree for any abnormalities (e.g., inflammation, masses, strictures, foreign bodies).
  4. Advancement of the bronchoscope into a segmental or subsegmental bronchus of the target lung area and wedging it to create a seal.
  5. Instillation of multiple aliquots (e.g., 20-60 mL per aliquot, total 100-300 mL) of sterile normal saline through the working channel of the bronchoscope into the lung segment.
  6. Gentle aspiration of the instilled fluid, along with cellular and soluble components from the alveolar space, into sterile collection traps.
  7. Repeat instillation and aspiration cycles (typically 2-5 times) to maximize fluid recovery and cellular yield.
  8. Withdrawal of the bronchoscope and post-procedure monitoring of the patient.
  9. Proper handling and transport of the collected BAL fluid to the laboratory for appropriate diagnostic studies (e.g., cell count and differential, cytology, cultures, special stains).

Coding Guidelines

  • CPT code 31628 includes the diagnostic bronchoscopy and the bronchoalveolar lavage. Do not report CPT code 31622 (Diagnostic bronchoscopy) in conjunction with 31628.
  • If additional separate diagnostic or therapeutic procedures (e.g., biopsy, brushings, foreign body removal, stent placement) are performed during the same bronchoscopy, they may be reported separately using their specific CPT codes, when clinically indicated and distinct from the BAL, potentially requiring modifier -59 (Distinct Procedural Service).
  • This code has a 0-day global period, indicating that only services rendered on the day of the procedure are included in the payment.
  • Appropriate documentation must include medical necessity for the BAL, the specific lung segment(s) lavaged, the volume of fluid instilled and recovered, and the type of laboratory analyses ordered for the specimens.
  • Sedation, if provided by the operating physician, is typically considered inherent to the procedure and not separately billable. If provided by a separate qualified healthcare professional, it may be reported with appropriate anesthesia codes.

Associated ICD-10 Codes