General Surgery Coding Alert

If you don't recognize when you can -- and can't -- separately report a biopsy and a procedure, you could be giving up deserved reimbursement.

Biopsies are vital procedures that general surgeons use in a multitude of locations on and in the body to diagnose and monitor many diseases. Follow these expert biopsy coding tips to ensure you capture every piece of the biopsy procedures your surgeon performs.

You should always wait until the pathology report comes back to choose the proper codes to report, even though this will not always affect the CPT code you will choose.

Reason: The biopsy specimen's pathology will affect the ICD-9 code you report, but most CPT procedure codes are not based on the specimen's results. "There are a few CPT codes which are linked to specific diagnoses (for instance, excision of benign and malignant lesions), but overall CPT is about what you did; ICD-9 is about the outcome or the reason for it," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

Example: Your surgeon performs a needle core breast biopsy for a patient with a breast mass. When the pathology report comes back, it indicates that the biopsy your surgeon took was of an axillary lymph node.

The pathology results do not change the service your surgeon performed into a lymph node biopsy. Therefore, you should report 19103 (Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance) for this breast biopsy procedure. There was a mass and your surgeon biopsied that mass.

"The fact that the tissue they brought back was lymph node tissue doesn't really change that," Bucknam says. "You performed a breast biopsy and you should code a breast biopsy. The fact that the very limited specimen you got returned as normal lymph tissue doesn't mean anything more than that."

ICD-9 help: You should report 611.72 (Signs and symptoms in breast; lump or mass in breast) as the diagnosis for this procedure. "There would be no way to code a diagnosis of 'normal lymph node,'" Bucknam says. Unless the surgeon "found some actual disease process in the lymph node, breast mass is going to be the diagnosis and breast biopsy should be the code," she adds Watch Out for Bundled Biopsy Coding When your surgeon performs an excision, removal, or destruction procedure, he may also perform a biopsy at the same time. Usually you cannot separately report the biopsy. Whether your surgeon performs the biopsy before the excision to verify that he's performing the excision in the right location or he performs a follow-up biopsy, the biopsy is an integral component of an excision and not separately reportable.

Rationale: The Correct Coding Initiative (CCI) guidelines support this advice, explaining, "If a biopsy is obtained for evaluation after the procedure is completed, the biopsy is not separately reportable with an excision, removal, destruction, fulguration, or other elimination procedure of the biopsied lesion."

Example: In most cases, you would not report a skin lesion biopsy (for example, 11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) at the same time as a more extensive excision procedure at the same location. For instance, the surgeon biopsies a skin lesion to verify the location, then follows up with an excision (such as 11603, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm). In this case, you would not report 11100 as well as 11603. "When the surgeon performs an excision, and the tissue sample is submitted for pathologic exam, the biopsy is considered by CPT to be a routine component of the excision procedure and is therefore not separately reported," explains Lynn Woolard, practice manager for General and Vascular Surgery in Elgin, Ill.

When the biopsy leads to the decision to perform the excision, however, you can report the biopsy separately. CCI guidelines specify, "If the biopsy is performed on the same lesion on which the 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 result of the pathologic examination."

In other words, if the surgeon documents that his decision to perform the excision was based on the results of a biopsy that preceded the excision, you can report both procedures, Bucknam explains. If the excision follows the biopsy, you can report only the excision.

Error averted: When you do report a biopsy and excision of the same location separately, add a modifier to the biopsy code to indicate that the biopsy prompted the excision. Medicare directs coders to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period). Many other payers will be looking for modifier 59 (Distinct procedural service) in this situation, however.