Biopsy Coding Requires an Eye for Detail
Does your provider’s documentation contain all the information you need for correct coding?
Unless the provider is descriptive in their documentation, it can be difficult to code biopsies for several reasons. For example, there are circumstances when you can report a biopsy with a more extensive procedure performed at the same surgical site, when you can report multiple biopsies, and when you can’t separately report a biopsy at all.
To sort things out when coding biopsies, you need to know:
- What type of biopsy is this?
- When is this biopsy reportable?
- How many biopsies may I report if there are multiples?
The CPT® code book and the National Correct Coding Initiative (NCCI) manual are always good places to start for guidance.
A biopsy, as defined by Stedman’s Medical Dictionary, is the process of removing tissue from the patient for diagnostic examination. When unsure whether a biopsy is superficial or deep, look to the CPT® code book. Per CPT®:
- Partial-thickness biopsies sample a portion of the thickness of skin or mucous membrane and do not penetrate below the dermis or lamina propria.
- Full-thickness biopsies penetrate into tissue deep to the dermis or lamina propria, into the subcutaneous or submucosal space.
What Type of Biopsy Is This?
There are several types of biopsies that the provider may perform using clinical judgement, which is difficult to code if not documented. If you can determine from the documentation whether the biopsy is partial-thickness or full-thickness, but the provider has not documented the type, finding other clues in the documentation may simplify coding.
The multiple types of biopsies defined by Stedman’s Medical Dictionary are:
Aspiration – Needle
Brush – Obtained by abrading the surface of a lesion with a brush to obtain cells and tissue for microscopic examination
Endoscopic – Obtained by instruments passed through an endoscope or obtained by a needle introduced under endoscopic guidance
Excision – Excision of tissue for gross and microscopic examination in such a manner that the entire lesion is removed
Fine-needle – The aspiration and removal of tissue or suspensions of cells through a small needle
Incision – Removal of only a part of a lesion by cutting into it
Needle – Any method in which the specimen is removed by aspirating it through an appropriate needle or trocar that pierces the skin, or the external surface of an organ, and into the underlying tissue to be examined
Open – Surgical incision or excision of the region from which the biopsy is taken
Punch – Any method that removes a small cylindrical specimen for biopsy by means of a special instrument that pierces the organ directly, through the skin, or through a small incision in the skin
Shave – Technique performed with a surgical blade or a razor blade; used for lesions that are elevated above the skin level or confined to the epidermis and upper dermis, or to protrusion of lesions from internal sites
Trephine – A tool used to perform a punch biopsy
Wedge – Excision of a cuneiform specimen
The CPT® code book guidance distinguishes between the biopsies coded in the Integumentary section:
- Tangential (shave, scoop, saucerize)
According to the CPT® code book, “sampling of stratum corneum only, by any modality (eg, skin scraping, tape stripping) does not constitute a skin biopsy procedure and is not separately reportable.”
If you are still unsure about the type of biopsy performed, query the provider.
Can I Report This Biopsy?
Chapter 1 of the NCCI manual describes when and when not to report a biopsy. There are certain surgical procedures for the integumentary system where submitting a specimen for pathologic examination is a routine component of those procedures. In those cases, it is not appropriate to report a biopsy as a separate procedure; however, there is a caveat to that statement.
NCCI Chapter 1.C. states that a biopsy performed on a separate lesion at the time of another more extensive procedure (e.g., excision, destruction, removal) is separately reportable by appending modifier 59 Distinct procedural service or XS Separate structure.
If the provider performs a biopsy for immediate pathologic evaluation (i.e., frozen section) to determine whether they should perform a more extensive procedure, report the biopsy separately in addition to the more extensive procedure.
If a preoperative diagnosis exists, however, do not report the biopsy separately. You must look at the pre-diagnosis on the operative note and read the Indications for Surgery section to determine whether a preoperative diagnosis has been made. This information may also be found on a pathology report or on a progress note in the patient’s medical record.
Separately report single skin lesions that are biopsied using a code from the Surgery/Integumentary System section in the CPT® code book.
Per NCCI Chapter 3.L.11, when a biopsy is performed to assess margins of resection or to verify resectability, you cannot report it separately.
Likewise, if a biopsy is performed during a more extensive procedure and submitted for future pathologic evaluation, the biopsy is not separately reported with the more extensive procedure.
Per NCCI, Chapter 3.L.12, fine needle aspiration (FNA) biopsies are not reported with another biopsy procedure code performed on the same lesion at the same encounter. For example, if during a procedure, the surgeon deems the FNA specimen is inadequate and obtains an additional biopsy specimen using a different biopsy procedure, the physician may report only the biopsy code or the FNA code.
When to Separate Procedures
Payers may consider a biopsy an overlapping service included in a more extensive surgical procedure. In such cases, the CPT® code description may include the phrase separate procedure. The Centers for Medicare & Medicaid Services (CMS) prohibits reporting a separate procedure-designated code with another anatomic-related procedure code when they are performed during the same encounter through the same skin incision, orifice, or surgical approach. It is incorrect to circumvent this guideline by citing the patient’s diagnosis.
You may report a separate procedure-designated code with another anatomic-related procedure code when it is performed at a separate encounter, through a separate skin incision, in a separate orifice (i.e., right nostril versus left nostril, right ear versus left ear), or a different surgical approach.
When it’s appropriate to use a CPT® code for a separate procedure, append modifier 59, XS, or a more specific modifier (e.g., anatomic modifier) to the “separate procedure” CPT® code to indicate that it qualifies as a separately reportable service.
Reporting Multiple Biopsies
A provider often takes multiple biopsies of a single lesion. In the CPT® code book, there are certain codes that account for single or multiple biopsies (for example, 45331 Sigmoidoscopy, flexible; with biopsy single or multiple). In other situations, coding multiple biopsies may be allowed.
Per the NCCI manual, Chapter 1 V.2.b, “If a code descriptor uses the plural form of the procedure, it must not be reported with multiple units of service. For example, if the code descriptor states ‘biopsies,’ the code is reported with ‘1’ unit of service regardless of the number of biopsies performed.”
For a single lesion that is biopsied multiple times, you may report only one biopsy code — open or endoscopic — with a single unit of service. If multiple lesions are non-endoscopically biopsied, a biopsy code may be reported for each lesion, appending modifier XS or 59. For endoscopic biopsies, report multiple biopsies of single or multiple lesions with one unit of service of the biopsy code.
To submit multiple biopsies of the same or different lesions for separate pathologic examination, the medical record must identify the precise location and separate nature of each biopsy to show medically reasonable and necessary.
Code With Confidence
Familiarize yourself with the types of biopsies and understand the NCCI guidelines. This will provide you with the know-how and confidence to query about inadequate documentation, to clear up the confusion, and to code accurately.
About the Author:
Winda F. Hampton, RHIA, CPMA, CCS-P, has more than five years’ experience as an outpatient surgical coder. She attended the University of Alabama at Birmingham, where she received a Bachelor of Science in Health Information Management. Hampton is a member of the Durham, N.C., local chapter.
Stedman’s Medical Dictionary, “Biopsy,” 28th edition, 2006, p 221-222
CMS. Chapter I, General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. 2019
CPT® code book, American Medical Association, 2019
ICD-10-CM code book, 2019