How to Be the Best Fine Needle Aspiration and Core Biopsy Coder

Doing so requires understanding the 2019 coding changes for reporting these two services during the same session.

Effective Jan. 1, 2019, new CPT® codes were introduced to report fine needle aspiration (FNA) biopsies. Proper coding of these procedures starts with an understanding of the new codes, as well as how they affect reporting of core biopsies performed during the same session as a FNA biopsy.

Change Details

Prior to 2019, most FNAs were reported with one of two codes: 10021 or 10022 (See the accompanying CPT® Codes sidebar for code descriptions). Code 10022 also required assignment of a corresponding radiological guidance code (76942, +77001, 77012, 77021).
For 2019, the FNA biopsy codes are expanded, and now reflect the imaging modality used when performing the FNAs. As such, it is no longer necessary to assign a corresponding radiological code. Add-on codes have also been established to report aspiration biopsy of additional lesions during the same session.
FNA procedures may be performed with imaging guidance. There are two codes available for FNA performed without imaging guidance. Code 10022 was deleted, and code 10021 was revised to capture FNA biopsy of first lesion without imaging guidance. Code +10004 was created as an add-on code to 10021 for each additional lesion biopsied without imaging guidance.
Other new codes are:

10005 and +10006 for FNA under ultrasound guidance

10007 and +10008 for FNA under fluoroscopic guidance

10009 and +10010 for FNA under computed tomography (CT) guidance

10011 and +10012 for FNA under magnetic resonance (MR) guidance

The American Medical Association (AMA) gives specific guidance concerning these codes in the CPT® instructional notes.

FNA Separate Lesions, Same Imaging Modality

Coding is straightforward when separate lesions are biopsied using the same type of imaging guidance. Select the appropriate primary code based on the imaging guidance used (ultrasound, fluoroscopic, CT, MR), and select the corresponding add-on code for any additional lesions. The imaging guidance add-on codes are used regardless of whether the lesions are located ipsilaterally or contralaterally and whether the lesions are in the same or different organs or structures.
Coding Example: FNA biopsy is performed on a left-sided thyroid nodule and a right-sided thyroid nodule, both under ultrasound guidance. The appropriate codes are 10005 and +10006.

FNA Separate Lesions, Different Imaging Modality

When separate lesions are biopsied, with each using a different type of imaging guidance, more than one primary code is assigned. The appropriate primary code is assigned based on the imaging guidance used for the first lesion. The second primary code is selected based on the imaging modality used for the second lesion.
When additional lesions are sampled using either modality, assign the corresponding add-on code for each additional lesion based on the imaging modality used. Append modifier 59 Distinct procedural service or another National Correct Coding Initiative (NCCI) modifier as necessary. As with a FNA biopsy performed with the same imaging modality, the location of the lesions (whether ipsilateral or contralateral to each other), or whether the lesions are in the same or different organs or structures, is not a factor and add-on codes should be assigned accordingly.
Coding Example: FNA biopsy is performed on a lesion in the right breast under ultrasound guidance, followed by a FNA biopsy of supraclavicular lymph node under fluoroscopic guidance. Proper coding is 10005 and 10007.

FNA and Core Biopsy of the Same Lesion

At times, both an FNA biopsy and a core needle biopsy may be performed at the same session. Aspirations may be performed with fine needles or a larger gauge needle and core needle biopsies may be performed with a fine needle or larger gauge cutting needles — needle gauge doesn’t affect coding.
A core needle biopsy uses a needle to acquire a tissue sample, which is sent for histology. This differs from an aspiration (FNA), during which a fluid sample is obtained and sent for cytology.
When a core needle biopsy is performed, both a surgical code based on the anatomical site and a corresponding guidance code are assigned. The surgical codes for core biopsy procedures are assigned one time per lesion. It is not appropriate to assign a core biopsy code multiple times for multiple passes of the same lesion. Guidance codes are reported one time per session.
Chapter 9 of the NCCI manual instructs:

CPT® codes 76942, 77002, 77003, 77012, 77021 describe radiological guidance for needle placement by different modalities. CMS payment policy allows only 1 unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not the number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

For 2019, the CPT® code book instructs not to separately report the imaging guidance for the core needle biopsy (+77002, 76942, 77012, 77021) when both FNA and core needle biopsy are performed on the same lesion, during the same session, using the same type of imaging guidance.
In Chapter 3 of the NCCI manual, past guidance concerning FNA and core biopsies during the same session is revised, and provides the following guidance, effective Jan. 1, 2019:

Fine needle aspiration (FNA) biopsies (CPT® codes 10004-10012, and 10021) shall not be reported with a biopsy procedure code for the same lesion. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the physician shall report only one code, either the biopsy code or the FNA code.

Coding Example: FNA biopsy of the liver mass is performed under ultrasound guidance, followed by a needle core biopsy. Proper coding is 47000 and 76942.
Note: Although CPT® allows reporting of FNA with a core biopsy (10005 and 47000), for Medicare patients, the NCCI manual precludes billing for both procedures.
The advice for 2019 differs from the guidance in prior versions of the NCCI manual, which allowed reporting of both the FNA and core biopsy of the same lesion when the FNA started as non-diagnostic, turned diagnostic, and resulted in a core biopsy being performed.

FNA and Core Biopsy, Separate Lesions

Both the core needle biopsy and imaging guidance (with modifier 59 appended) may be reported separately when a FNA biopsy is performed on one lesion and a core needle biopsy is performed on a separate lesion during the same session using the same type of imaging guidance. Both the core needle biopsy and imaging guidance (with modifier 59) may be reported when each is performed with a different type of imaging guidance.
Coding Example 1: A core biopsy is performed of an axillary lymph node under ultrasound guidance, followed by a FNA biopsy of the thyroid under ultrasound guidance. Proper coding is 38505, 76942-59, and 10005.
Coding Example 2: A FNA biopsy of an inguinal lymph node is performed under ultrasound guidance, followed by a core needle biopsy of an intra-abdominal mass under CT guidance. Proper coding is 10005, 49180, and 77012.

CPT® Codes

 
Resource
NCCI manual, chapter 3 and chapter 9:
www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html

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Stacie Buck, RHIA, CIRCC, CCS-P, RCC

Stacie L. Buck, RHIA, CIRCC, CCS-P, RCC, RCCIR, AAPC Fellow, is president and senior consultant at RadRx in Stuart, Fla. (www.radrx.com). She is a national speaker who provides consulting services to providers of diagnostic and interventional radiology services and is the author of the book Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding and creator of Mastering Interventional Radiology & Cardiology Online Education Program. Buck may be contacted at sbuck@radrx.com. She is a member of the Stuart, Fla., local chapter.

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