General Surgery Coding Alert
Obtain Proper Reimbursement for Breast Biopsies
There are several procedures that fall under the category of breast biopsy, and even more codes to describe them; so general surgeons need to be specific about the procedure performed in their operative reports. Similarly, coders need to familiarize themselves with the different types of breast biopsies and then carefully read the operative report to determine how best to code what their surgeon did.
Given the proliferation of breast biopsy codes, the most important thing a coder needs to do before billing out such procedures is to determine exactly what procedures were performed, says Cynthia Swanson, RN, CPC, a coding and reimbursement specialist with Seim, Johnson, Sestak & Quist, an accounting firm in Omaha, Neb. The physician may not be descriptive enough in their narrative, however, so coders need to impress upon their doctors the importance of improving their descriptions of these procedures, maintains Swanson. That, of course, doesn't solve the immediate problem of figuring out just which procedures actually were performed. "If you can't understand what the op note says, you have to go the physician and ask him or her to tell you," Swanson says. Mostbut not allbreast biopsy procedure codes are located in the 19000-section of the CPT manual. The differences among these procedures depend on the kind of tissue being excised and the method used to access it. At a glance, some of these procedures resemble each other. For example, coders without a clinical background easily may confuse codes 19000 (puncture aspiration of cyst of breast), 19100 (biopsy of breast, needle core [separate procedure]), 19101 (biopsy of breast, incisional), and 19120 (excision of cyst, fibroadenoma or other benign or malignant tumor aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], male or female, one or more lesions).
The confusion is compounded once other techniques, such as fine needle aspiration (88170, fine needle aspiration with or without preparation of smears; superficial tissue [e.g., thyroid, breast, prostate]) and stereotactic breast biopsies are considered. In short, the problem for coders is how to distinguish among the various procedures.
Palpable Lesions
When a patient presents with a breast lump that can be palpated (i.e., felt by the surgeon through the skin), the surgeon likely will try to determine if it contains mostly fluids or solids. If the lump is a cyst, the surgeon will try to suck out the fluid with a syringe. This procedure is coded 19000. If there are additional cysts, code 19001 (each additional cyst [list separately in addition to code for primary procedure]) is used for each additional one. After all the fluid is removed, if a solid mass remains, the surgeon most likely will perform an excisional biopsy (19120).
Note: If only a portion of the mass is removed, incisional biopsy code 19101 would be more appropriate.
If the palpated lump feels solid, fine needle aspiration (88170) is performed to pull up some cell particles to send to the lab for cytology, which basically consists of the preparation of smears, according to M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. If radiology is used to guide the needle to the mass, one of three accompanying radiology supervision and interpretation (S&I) codes76003 (fluoroscopic localization for needle biopsy or fine needle aspiration), 76360 (computerized tomography guidance for needle biopsy, radiological supervision and interpretation), or 76942 (ultrasonic guidance for needle biopsy, radiological supervision and interpretation)also should be billed. If the procedure is performed in the hospital, modifier -26 (professional component) should be attached to the appropriate radiology code because even though the surgeon is performing the procedure, he or she is using the hospital's equipment.
If the cytology report based on the aspirated cells from the breast lump returns positive, the surgeon may perform needle core biopsy (19100) using a hollow needle to take a core sample of the breast tissue or an incisional biopsy (19101) so that it can be examined under a microscope.
"Many surgeons feel uncomfortable performing a lumpectomy or mastectomy based on a cytology report alone," Dunaway says. "You need a tissue sample, and the needle core or open biopsy gives you that. Then, if the tissue is malignant, you proceed with the lumpectomy or mastectomy."
Nonpalpable Lesions
When the surgeon cannot palpate the lump or lesion but is aware of its existence because of mammography, other means must be used to find the exact location of the lump so that a biopsy can be taken.
One widely practiced method of locating and sampling nonpalpable breast masses is the stereotactic breast biopsy. In this procedure, mammograms taken at different angles locate a breast lesion, after which a needle "gun" automatically is moved into position by a linked computer system. Additional images are taken to confirm the location of the lesion, then the needle is passed through the skin into the breast and a biopsy performed. Approximately five samples typically are obtained, though many more often are biopsied.
From a coding perspective, the most important thing to note is that there is no single procedure code for the stereotactic breast biopsy. Instead, a combination of biopsy and radiology codes are used to bill for the service. For example, if a woman presents with a mammogram that indicates a nonpalpable mass in her left breast, the stereotactic breast biopsy would be coded as follows:
Note: Code 76095 may be used only if the radiologist is not present during the procedure.
If the patient has more than one suspected mass, the procedure may be billed again. If, for example, a four-quadrant biopsy is performed, however, that's still one biopsy, says Cindy Parman, CPC, an independent coding and reimbursement specialist in Dallas, Ga. "The rule is: one biopsy per needle placement, not one biopsy per tissue removed. In other words, if the needle is placed more than once, you get to charge more."
The method of reporting the additional biopsy or biopsies varies by carrier. Some carriers may instruct providers to enter the number of biopsies performed in the units box of the HCFA 1500 claim form, Parman says, adding that this applies both to the appropriate radiology and biopsy codes.
For their part, Medicare carriers prefer modifier -59 (distinct procedural service) to be used to indicate that the procedure was performed on a separate site (i.e., a second lesion) in the breast. If the second lesion is on the Medicare patient's other breast, modifier -50 (bilateral procedure) should be used, although some carriers may prefer modifiers -RT (right side) and -LT (left side) on two separate lines.
Note: Adding more units or using modifier -59 applies only if there is more than one lesion requiring separate localizations (i.e., the needle needs to be reconfigured to the location of the other mass). Regardless of how many tissue samples from the same mass are removed, the stereotactic breast biopsy may be reported only once.
Many Medicare carriers now also cover stereotactic breast biopsy for palpable lesions in some circumstances. Because performing a stereotactic breast biopsy is considered more difficult when the lesion is nonpalpable, some carriers (for example, Palmetto Government Benefits Administrators in South Carolina and WPS in Wisconsin and Illinois) instruct providers to distinguish between the two as follows:
Note: Because the biopsy of a nonpalpable lesion is considered more complex than that of a palpable mass, 19101, which pays more than 19100, is used even though an incision, strictly speaking, has not been performed.
Usually, radiographic analysis is medically necessary to verify the biopsy sample. For example, the mammogram(s) that prompted the stereotactic biopsy may have shown calcification, which occasionally is associated with cancer in the breast. An x-ray is then taken of the removed biopsy material to verify the presence of calcifications. If the mass is large, however, the portion removed by the stereotactic biopsy may not contain tissue exhibiting calcification. So once the biopsy is removed, the breast itself is x-rayed again to make sure the mammographic mass (i.e., the portion with calcification) was indeed biopsied. This procedure is coded 76098 (radiological examination, surgical specimen) and is billed as one unit of service per specimen examined.
Mammography services may not be billed in addition to the stereotactic procedure; such services are included in 76095. According to a policy statement by WPS, neither the technical nor complete procedure for 76095 is billable to Medicare Part B when the procedure is performed in an inpatient setting; it would be considered a Part A service. In this situation, modifier -26 should be used to identify the professional component only when billing Part B. The WPS statement also notes that documentation supporting medical necessity of the service, such as ICD-9 codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.
Needle Placement for Nonpalpable Lesions
Depending on the precise location of the mass inside the woman's breast, stereotactic biopsy may not be an option. In these situations, an older technique is used to locate the nonpalpable lesion. In this technique known as needle placement (19290, preoperative placement of needle localization wire, breast), the radiologist or the surgeon punctures the skin over the lesion and inserts a needle threaded with a wire that is guided radiologically into the mass. The wire helps identify the nonpalpable mass that is to be removed or biopsied.
Any additional lesions identified by needle placement are coded 19291 (each additional lesion). The radiology S&I code is 76096 (preoperative placement of needle localization wire, breast, radiological supervision and interpretation) and is billed once per localization. If the procedure is performed in the hospital, modifier -26 (professional component) should be attached if the surgeon, not the radiologist, performed the S&I.
The biopsy of a lesion identified by needle placement has its own codes (19125, excision of breast lesion identified by preoperative placement of radiological marker; single lesion; 19126, each additional lesion separately identified by a radiological marker), even though it is excised much the same as a palpable mass that, if excised would be billed 19120.
General Surgery Coding Alert
- Obtain Proper Reimbursement for Breast Biopsies
Nugget: If the operative report isn't clear, coders should ask their physicians what procedure was [...] - Pathology Report Critical to Lesion Excision Coding
Nugget: If a surgeon excises more tissue to remove margins and the lesion turns out [...] - You Be the Coder:
Diagnosing Breast Lumps
Test your coding knowledge. Determine how you would code this situation before looking at the [...] - Case Study:
Documenting Separate Incisions Can Get Two Procedures Paid
Nugget: Coders can find critical information by carefully reading the body of the surgeon's operative [...] - Look for Corrections to CCI Version 6.1 Errors
Nugget: The errors in the initial release of CCI version 6.1 involved the incorrect assignment [...] - Reader Question:
Second Procedures Billed With Modifier -59
Question: On occasion, a patient needs both an upper and lower endoscopy (EGD and colonoscopy) [...] - Reader Question:
National Physician Fee Schedule
Question: Can you tell me how to find out global periods for each of the [...]
