Revenue Cycle Insider

Question: A patient presented to radiology for a superficial axillary lymph node core needle biopsy. The doctor thinks I should assign a breast biopsy code, but I don’t think that’s correct. I’m very new to coding, so could you point me in the right direction as to what code I should report for the procedure?

Oklahoma Subscriber

Answer: You are correct — a breast biopsy code is the wrong choice for the procedure. You’ll assign 38505 (Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary)) to report the core needle biopsy of the superficial axillary lymph node. These lymph nodes are located in the armpit near the surface of the body, not in the breast tissue.

Also, double-check the physician’s documentation to confirm whether they used imaging guidance to perform the procedure. Depending on the imaging equipment used, you’ll assign one of the following codes:

• 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation)
• +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure))
• 77012 (Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation)
• 77021 (Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation).

Mike Shaughnessy, BA, CPC, Production Editor, AAPC