Bundled or Separate Biopsy Depends on Circumstances

Look to NCCI policy for the two-specific conditions that call for unbundling.

By Brad Ericson, CPC, COSC

A biopsy performed on the same date of service as a more extensive procedure—such as an excision, destruction, or removal—generally is bundled into that more extensive procedure. But, under two-specific conditions for Medicare and most other payers, a same-day biopsy and more extensive procedure may be reported independently. The qualifying circumstances are outlined specifically in chapter 1 of the National Correct Coding Initiative (NCCI) “General Correct Coding Policies.”

1. “If the biopsy is performed on a separate lesion, it is separately reportable. This situation may be reported with anatomic modifiers or modifier 59.”

For example, the physician biopsies a lesion on the left breast, and excises a lesion of the right breast. Depending on payer preference (check with your payer), you may report the appropriate biopsy code with modifier LT Left side and the appropriate excision code with modifier RT Right side; or, you may report the excision code (the “most extensive” procedure) without a modifier, and append modifier 59 Distinct procedural service to the biopsy code.

2. “If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination.”

In other words, if the results of the biopsy prompt the physician to perform a more extensive procedure, both the more extensive procedure and the biopsy may be reported.

As an example, consider a patient with a suspicious lesion on the forearm: If the physician excises the lesion and sends it to pathology, we know that the biopsy is not reported separately because, as NCCI explains, “If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure.”

Suppose, however, that the physician sends a portion of the suspicious lesion for examination, and pathology confirms a malignancy. The physician proceeds to excise the entire lesion. In this case, because the biopsy led to the decision to perform the more extensive procedure, both the excision (e.g., 11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm) and the biopsy (11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion) may be reported separately. NCCI instructs you to append modifier 58 Staged or related procedure or service by the same physician during the postoperative period to the excision code (11603), “to indicate that the biopsy and the more extensive procedure were planned or staged procedures.”

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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