General Surgery Coding Alert

Distinguish Aspiration From Biopsy

To determine whether you should report fine needle aspiration (FNA: 10021-10022) or percutaneous needle biopsy (PNB: 19100-19103), consider two points:

1. Needle size: "A percutaneous needle is much larger than a fine needle," says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist in Brick, N.J.

In FNA, the physician uses a fine-gauge needle (from 18 to 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. The surgeon may make several passes to obtain an adequate tissue specimen.

PNB, in contrast, involves a single insertion to remove a "core" sample of tissue from the lesion.

2. Specimen type. A fine needle takes out an "aspirate," which is typically a mixture of fluid and cells that the surgeon sends for analysis, Cobuzzi says. "A percutaneous needle is larger and takes out tissue in the mass's core," she says.

Remember: Open incisional biopsy (19101) is distinct from FNA or PNB because the surgeon would not use a needle to collect the specimen.

Report FNA Evaluation Separately

If the surgeon checks an FNA under the microscope to ensure he has an adequate sample, you should report 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) in addition to 10021 or 10022, says Melanie Witt, RN, MA, CPC, a surgical coding expert based in Fredericksburg, Va. The surgeon then normally sends the cells to the pathologist for evaluation. The lab will report its service separately using 88173, ... interpretation and report.

Don't Forget Imaging Guidance

You can report imaging guidance separately for procedures 10022, 19102 and 19103 if the surgeon supervises and interprets the results.

Choose from among the following codes, depending on whether the surgeon selects fluoroscopic, computed tomography, magnetic resonance or ultrasonic guidance:

Localization Clips Are Extra, Too
 
If the surgeon places a postbiopsy localization clip to mark the site, you should report +19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy [list separately in addition to code for primary procedure]).

Recognize the limits: Code 19295 is an add-on code that you should report only with PNB procedures 19102 and 19103.

"In case more definitive surgery is needed [following biopsy], the surgeon marks the spot of the biopsy," says Kim Garner, CPC, CCS-P, CHCC. For instance, if the biopsy report returns malignant, the surgeon may have to go back and remove additional tissue.

Be aware: Although proper coding dictates that you should report 19295 if the surgeon places localization clips, this service has no physician payment component. The facility will receive reimbursement for the cost of the clips, but the surgeon will not gain additional payment for the placement.

Turn to Modifiers for Multiple Biopsies

If the surgeon performs more than one biopsy, you would reflect this by using modifier 50 (Bilateral procedure) or modifier 59 (Distinct procedural service), depending on the circumstances.

The challenge is that you won't find a standard protocol for submitting claims for bilateral procedures, says Sangeeta Parekh, CPC, practice plan administrator for the USC Department of Surgery, Division of Tumor and Endocrine Surgery, in Los Angeles.

Example 1: The surgeon performs percutaneous biopsy with CT imaging guidance of a single lesion on each of the right and left breast. Because the lesions are on separate breasts, you should report 19102-50 for the biopsies with 76360-26 for the imaging.

You don't need a multiple-procedure modifier with 76360, but you should append modifier 26 unless the surgeon performed the guidance in his own office and using his own equipment.

Example 2: The surgeon performs percutaneous biopsy with ultrasonic guidance for two separate lesions on the same breast. In this case, you should report 19102 for the first biopsy, 19102-59 for the second biopsy (which occurs at a separate anatomical location on the same breast) and 76942-26 for the ultrasound guidance.

Skip Separate Wound Closures

In most cases, if the surgeon performs a breast biopsy, he will only extract a small portion of the lesion. For this reason, you're not likely to report additional codes for wound closure or skin grafts, Witt says.

In addition, 19100, 19102 and 19103 include creation of a small skin incision to ease the insertion of the needle into the lesion. The surgeon's use of suture or Steri-Strips to close the incision is included in the procedure. You should not bill for this separately.