CPT code 31654 – EBUS bronchoscopy for peripheral lesions

Key takeaways

CPT 31654 describes EBUS bronchoscopy for peripheral lesions, not mediastinal stations, and that distinction decides which EBUS code you bill.

31654 is an add-on code billed with a primary bronchoscopy code, such as 31622 to 31625, 31628 or 31629. Without one, payers deny the claim as an add-on without an eligible primary procedure code.

The 31654 descriptor bundles fluoroscopic guidance, so you cannot report it separately on the same date.

Report each of 31652, 31653 and 31654 only once per session. Also, 31654 can pair with either mediastinal code when you sample both sites.

Pabau, the practice software we build, tracks and submits claims through Claim.MD, with eligibility checks and ERA remittances alongside each claim.

CPT code 31654: Official descriptor and procedure overview

CPT code 31654 is the add-on endobronchial ultrasound (EBUS) code for reaching and sampling peripheral lung lesions during bronchoscopy. The official American Medical Association (AMA) descriptor reads:

“Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure).”

Three elements of this descriptor carry billing weight. First, “including fluoroscopic guidance, when performed” bundles fluoroscopy, so you cannot report a separate imaging guidance code alongside 31654. Second, “peripheral lesion(s)” limits the code to targets outside the mediastinum. Third, the “List separately in addition to” instruction confirms add-on status.

What CPT 31654 covers and what it excludes

CPT 31654 bundles the EBUS guidance component and fluoroscopic imaging into a single add-on payment. However, the services it leaves out decide as many claims as the ones it includes.

Included in 31654:

• Radial-probe or mini-probe EBUS navigation to a peripheral pulmonary nodule or mass
• Fluoroscopic guidance used during the same bronchoscopic session
• Ultrasound confirmation of probe position at the lesion

Excluded from 31654:

• EBUS of mediastinal or hilar lymph nodes, which you report with 31652 (1-2 stations) or 31653 (3+ stations)
• Separate imaging guidance codes (e.g., 76000, 77002), which are not separately reportable when 31654 is on the claim
• Navigation bronchoscopy (add-on 31627), which you report separately
• Transbronchial biopsies performed without EBUS guidance, which use different procedure codes

The AMA parenthetical instructions in the CPT codebook name the primary codes 31654 may accompany. If you bill it with a code outside that list, payers deny the claim as an add-on without an eligible primary procedure code.

How the EBUS peripheral-lesion procedure is performed

Each clinical step below leaves a trace in the operative note, and coders check those traces against the code being billed.

1. Patient positioning and anesthesia: The care team sedates the patient or uses general anesthesia. Then the bronchoscopist passes a flexible bronchoscope through the nose or mouth into the tracheobronchial tree.
2. Peripheral navigation: The bronchoscopist advances the scope into subsegmental bronchi toward the target lesion, using fluoroscopic imaging to confirm direction. This is why the descriptor bundles fluoroscopy.
3. EBUS probe deployment: The bronchoscopist threads a radial-probe EBUS catheter through the working channel of the bronchoscope. The rotating probe generates a 360-degree ultrasound image to confirm the probe is within or right next to the peripheral lesion.
4. Lesion confirmation: The classic “blizzard sign” on radial EBUS confirms probe position. The operative note must describe this finding to support medical necessity.
5. Sampling: The bronchoscopist advances biopsy forceps, a cytology brush, or transbronchial needle aspiration (TBNA) tools through the guide sheath to sample the lesion. Each sampling method may also carry its own CPT code that you bill alongside 31654.
6. Withdrawal and documentation: The bronchoscopist dictates or types the procedure report immediately, noting the peripheral location, number of passes, EBUS confirmation, and fluoroscopic use.

That final step decides whether the claim holds up. For example, a thin operative note leaves the payer no evidence that the target was peripheral, however well the procedure went.

CPT 31654 vs. 31652 vs. 31653: Choosing the right EBUS code

The three EBUS codes cover three different targets. 31652 and 31653 are standalone convex-probe codes, while 31654 alone is an add-on. Picking the wrong one trips NCCI edits and looks like upcoding to payers who audit bronchoscopy claims.

You bill either 31652 or 31653 based on station count, never both. However, you can report 31654 alongside either one when the bronchoscopist samples both peripheral and mediastinal targets in the same session.

Report each of 31652, 31653 and 31654 only once per session, however many lesions or passes the note records. Also, append modifier 59 when the NCCI edit requires it, and document each distinct site and the EBUS technique used at each. Finally, the panel below sets the three codes side by side.

Primary bronchoscopy codes that CPT 31654 can be reported with

As an add-on code, CPT 31654 requires a payable primary bronchoscopy code on the same claim. The AMA parenthetical instructions in the current CPT codebook name the eligible primary codes, including the ones below. Without one, payers deny the claim as an add-on without an eligible primary procedure code.

The table lists common primary codes, not every eligible one. When the peripheral lesion is sampled by transbronchial lung biopsy, 31628 is the primary code that 31654 is billed with.

Therefore, always verify the current-year AMA CPT codebook for the complete parenthetical list. The list has changed in prior annual updates, so billing from an outdated edition is a common source of denials.

Documentation requirements for a 31654 claim

Payers reviewing CPT 31654 claims look for specific language in the procedure note, beyond confirmation that bronchoscopy was performed. Clean claim submission for this code depends on seven documentation elements.

• Peripheral location confirmed: The note must state that the target lesion is peripheral (not mediastinal, not hilar). Reference the specific lobe and segment (e.g., “right upper lobe posterior segment”).
• EBUS probe type and use: State that a radial-probe or mini-probe EBUS catheter was used. Describe what it showed (e.g., “blizzard sign confirming probe within the lesion”).
• Fluoroscopic guidance documented: If fluoroscopy was used, note it. The “when performed” language means you can still bill 31654 without it, but document the absence to avoid auditor questions.
• Medical necessity statement: Include the clinical indication (e.g., “2.1 cm right upper lobe nodule identified on CT chest, PET-avid, requiring tissue diagnosis”).
• Number of passes: Record how many biopsy passes were taken and the instruments used at the peripheral site.
• Lesion size and imaging correlation: Reference the pre-procedure CT or PET scan that identified the peripheral lesion.
• Distinct service from any mediastinal sampling: If 31652 or 31653 is also billed, the note must separate the peripheral-lesion work from the mediastinal-station work.

In addition, the diagnosis on the claim has to match that indication. A solitary pulmonary nodule found on CT is reported with ICD-10-CM R91.1, linked to the 31654 line when it is the reason for the procedure. Once pathology confirms a primary lung cancer, later claims carry a C34 code. Code C34.90 is kept for a record that names no site or side.

Pulmonology billing compliance requirements mean this documentation must be in the record before the claim is submitted. In contrast, late addenda carry much more audit risk.

Modifiers for CPT code 31654

CPT 31654 is an add-on code, which removes some of the modifier complexity that applies to standalone procedure codes. However, a few modifiers still apply in common situations.

Add-on codes are not subject to the multiple-procedure payment reduction that applies to independent procedures, so you do not append modifier 51 to 31654. Likewise, Medicare does not reduce add-on code payment based on a bilateral reduction either. When the NCCI edit calls for modifier 59 on 31654, documentation must clearly describe the two distinct target sites.

Medicare reimbursement and RVUs for CPT 31654

CPT 31654 carries its own RVU value as an add-on code. Because it is an add-on, its payment escapes the multiple-procedure reduction that cuts second and later independent procedures in a session. The CMS Physician Fee Schedule lookup tool is the best source for current payment amounts, which change every year and vary by locality.

Use the FastRVU 2026 lookup tool to retrieve current work, practice expense, and malpractice RVU values by modifier and setting. Key payment concepts for 31654:

• Facility vs. non-facility rates differ. Hospital outpatient departments and ambulatory surgical centers typically perform bronchoscopy. That facility setting carries a lower physician fee schedule payment than a non-facility office setting, so confirm the place-of-service code on every claim.
• No bilateral reduction. Add-on codes are exempt from the bilateral billing reduction that cuts independent procedure payments when both sides are performed.
• Commercial rates vary by payer contract. Commercial payers negotiate their rates separately from Medicare.
• Annual updates apply. Do not use prior-year RVU data, because the CMS fee schedule updates on January 1 each year.

Once a payer pays a 31654 claim, check the remittance against the expected amount for your locality. Pabau, through Claim.MD, returns ERA remittances so your team can reconcile payments against what was expected.

Prior authorization requirements by payer

Prior authorization for EBUS peripheral-lesion bronchoscopy is not uniform across payers. Medicare does not require prior auth for most EBUS procedures, but commercial insurers frequently do, and their policies differ from plan to plan.

When a commercial payer requires prior auth and the practice does not obtain it, payers rarely reverse the resulting denial on appeal. Instead, build a standing prior-auth step into EBUS bronchoscopy scheduling rather than chasing authorizations after the procedure.

Common claim denial reasons for CPT 31654 and how to prevent them

EBUS peripheral-lesion claims fail for common reasons. In fact, knowing the denial pattern before submission is the cheapest form of denial management.

For specific denial codes in medical billing, review the ERA after each denial. CARC 4 means the action is inconsistent with the procedure code billed. Meanwhile, CARC 97 means payment is included in the allowance for another service, the usual signal of an NCCI bundling edit on a 31654 claim.

How Pabau supports clean CPT 31654 claims

The 31654 errors in this guide start before the claim exists. For example, a missing primary code, a vague operative note and an automatic modifier 59 are coding and documentation decisions your team makes.

Pabau takes over once those codes are set. Its claims software for practices tracks and submits claims through Claim.MD, to payers on the Claim.MD payer list. Eligibility checks, claim tracking and ERA remittances run through Claim.MD as well.

When payers deny a 31654 line, the CARC and RARC codes come back on the remittance. Your team can then spot a repeat pattern, such as a missing modifier on every 31654 and 31652 pair, and fix it at the source.

Keep every 31654 claim moving after submission

Pabau tracks and submits claims through Claim.MD, with eligibility checks, claim tracking and ERA remittances in one place. Your team spends less time chasing claim status by phone.

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Conclusion

CPT 31654 pays for one thing: radial-probe EBUS that reaches a peripheral lesion. The claim holds up when the operative note proves the target was peripheral and an eligible primary code sits on the same claim.

Start with the note template, because a coder cannot add what the bronchoscopist did not write. Then keep modifier 59 for the cases where the NCCI edit asks for it, instead of every 31654 and 31652 pair.

Pabau handles the step after coding, with eligibility checks, claim tracking and ERA remittances through Claim.MD. Book a demo to see how a pulmonology claim moves from submission to payment in Pabau.

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