Summary & Overview

CPT 31654: Bronchoscopy with Intrathoracic Ultrasound Guidance

CPT code 31654 is an add-on code for bronchoscopy procedures that use intrathoracic (tracheal and/or bronchial) ultrasound guidance to evaluate and treat peripheral lung lesions, with or without fluoroscopy. This specialized technique enhances lesion localization and sampling during rigid or flexible bronchoscopy and is increasingly relevant as minimally invasive diagnostic and therapeutic approaches to pulmonary nodules expand nationally.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Coverage and payment policies for ultrasound-guided bronchoscopic procedures vary across commercial insurers and Medicare, affecting patient access and site-of-service selection.

Readers will find a concise overview of the clinical context for CPT code 31654, typical sites of service, and the service type. The publication summarizes payer coverage considerations, common billing modifiers, and related coding context where available. It also highlights operational implications for hospitals and ambulatory surgical centers, including equipment and personnel considerations tied to intrathoracic ultrasound and optional fluoroscopy. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare31654CPTbronchoscopyendobronchial ultrasoundperipheral lung lesionsinterventional pulmonologyhospital-outpatientambulatory-surgery

Billing Code Overview

CPT code 31654 describes an add-on endoscopic procedure using intrathoracic ultrasound guidance performed in conjunction with rigid or flexible bronchoscopy. The procedure involves using ultrasound within the trachea and/or bronchi to evaluate and treat peripheral pulmonary lesions, and may be performed with or without fluoroscopic (live X-ray) assistance.

Service type: Diagnostic and therapeutic endoscopic ultrasound–assisted bronchoscopy

Typical site of service: Hospital operating room, ambulatory surgical center, or hospital outpatient department

Clinical & Coding Specifications

Clinical Context

A 64-year-old patient with a history of smoking and an indeterminate 2.5 cm peripheral pulmonary nodule on chest CT is scheduled for diagnostic bronchoscopy with endobronchial ultrasound guidance. The procedure is performed in an ambulatory surgery center under monitored anesthesia care. The pulmonologist inserts a flexible bronchoscope into the trachea and advances into the bronchi to localize the peripheral lesion using endobronchial ultrasound imaging; transbronchial needle aspiration or biopsy is performed during the same session, with fluoroscopy used intermittently for localization. Pre-procedure workflow includes informed consent, review of imaging, coagulation status check, and anesthesia evaluation. Intra-procedure workflow includes airway management, real-time ultrasound imaging through the bronchoscope (add-on service represented by 31654), specimen collection, hemostasis assessment, and documentation of ultrasound use. Post-procedure workflow includes recovery monitoring, pathology specimen handling, post-procedure instructions, and final operative note documenting ultrasound guidance, lesion targeted, samples obtained, and any complications.

Coding Specifications

Modifier	Description	When to Use
`11`	Country-specific or payer-designated standard modifier indicating the correct coding and typical service	Use when the service is performed as described without unusual circumstances (often default; payer-specific usage varies).
`22`	Increased procedural services	Use when work required to perform the procedure is substantially greater than typically required.
`52`	Reduced services	Use when the procedure is partially reduced or not completed as planned.
`53`	Discontinued procedure	Use when the procedure is started but terminated due to extenuating circumstances.
`59`	Distinct procedural service	Use when a separate, distinct procedure is performed on the same day that is not typically bundled.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct portions of the procedure.
`63`	Procedure performed on infants less than 4 kg	Use when applicable to neonates meeting weight criteria.
`66`	Surgical team	Use when a surgical team performs the procedure for complex cases.
`78`	Return to the operating/procedure room for a related procedure during the global period	Use when an unexpected return to the procedure area for a related issue occurs.
`80`	Assistant at surgery	Use when a qualified assistant surgeon participates.
`81`	Minimum assistant at surgery	Use when minimum assistant participation is documented.
`82`	Assistant not available, assistant required	Use when a qualified resident or assistant who would normally assist is not available.
`QX`	CRNA service with medical direction by physician (modifier QX)	Use when a certified registered nurse anesthetist provides anesthesia without medical direction.
`QY`	Medical direction of 2–4 concurrent anesthesia procedures	Use when the anesthesiologist directs multiple concurrent anesthesia procedures.
`RT`	Right side	Use when laterality needs designation for bilateral or side-specific reporting.

Taxonomy Code	Specialty	Notes
`207RP0000X`	Pulmonary Disease	Pulmonologists commonly perform bronchoscopic procedures with endobronchial ultrasound.
`2084P0800X`	Thoracic Surgery	Thoracic surgeons perform bronchoscopy and ultrasound-guided biopsies in operative settings.
`208000000X`	General Surgery	General surgeons with advanced endoscopic training may perform airway/bronchoscopic procedures.
`363L00000X`	Interventional Pulmonology	Specialists in advanced bronchoscopic techniques, including peripheral lesion biopsy with EBUS.
`286600000X`	Anesthesiology	Provides monitored anesthesia care or general anesthesia for bronchoscopic procedures.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C34.90`	Malignant neoplasm of unspecified part of bronchus or lung, unspecified side	Peripheral pulmonary nodules suspicious for primary lung cancer are a primary indication for bronchoscopic ultrasound-guided biopsy.
`R91.8`	Other nonspecific abnormal finding of lung field	Indeterminate pulmonary nodules on imaging prompting bronchoscopic evaluation with ultrasound guidance.
`J98.4`	Other disorders of the lung, not elsewhere classified	Used for atypical pulmonary findings necessitating diagnostic bronchoscopy with ultrasound.
`J84.10`	Pulmonary fibrosis, unspecified	Interstitial or peripheral lung disease with focal abnormalities that may require targeted sampling under ultrasound guidance.
`R04.2`	Hemoptysis, unspecified	Hemoptysis may prompt bronchoscopic evaluation; ultrasound guidance can assist safe targeting and control during biopsy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`31622`	Bronchoscopy, rigid or flexible, diagnostic, with or without cell washing (separate procedure)	Often performed as the primary airway endoscopy during which `31654` (ultrasound guidance) is added for peripheral lesion localization.
`31628`	Bronchoscopy, flexible, transbronchial lung biopsy(s), single lobe	Transbronchial biopsy may be performed after ultrasound localization; supports tissue diagnosis.
`31629`	Bronchoscopy with transbronchial lung biopsy, each additional lobe (List separately in addition to code for primary lobe)	Used when multiple lobes are sampled in the same session following EBUS localization.
`31635`	Bronchoscopy with transbronchial needle aspiration biopsy(s) of the lung, single lobe	Commonly used for needle aspiration of peripheral lesions identified with ultrasound guidance.
`77012`	Fluoroscopic guidance for needle placement (radiological supervision and interpretation)	Fluoroscopy is frequently used alongside `31654` to assist localization and needle placement for peripheral biopsies.
`36415`	Collection of venous blood by venipuncture	Pre-procedure labs including coagulation studies are often obtained prior to bronchoscopy and biopsy procedures.