Coding for Biopsy with a Related, More Extensive Procedure

Although you may not separately report (or receive reimbursement for) a biopsy following a more extensive procedure, such as an excision, at the same anatomic location and patient encounter, you may report the biopsy separately if it precedes and leads to the more extensive procedure. This rule is explained in Chapter IV of the National Correct Coding Initiative Policy Manual for Medicare Services:

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. The biopsy is not separately reportable if the pathologic examination at the time of surgery is for the purpose of assessing margins of resection or verifying resectability.

The Policy Manual further asserts, “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.”

In other words: If a biopsy at the same anatomic location/patient encounter precedes a more extensive procedure (such as an excision, destruction, or removal), you may report both procedures. If the more extensive procedure precedes the biopsy, do not report the biopsy separately.

When reporting a biopsy with a more extensive procedure at the same location, append modifier 58 Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period to the biopsy code to indicate that the biopsy prompted the excision. Per the Policy Manual, “When separately reportable modifier 58 may be reported to indicate that the biopsy and the more extensive procedure were planned or staged procedures.”

If a biopsy and more extensive procedure occur at separate anatomic locations, you may report the procedures independently by appending modifier 59 Distinct Procedural Service to the appropriate biopsy code. Per the Policy Manual, “If the biopsy is performed on a separate lesion, it is separately reportable. This situation may be reported with anatomic modifiers or modifier 59.”

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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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