General Surgery Coding Alert

Question: If the surgeon performs both a fine needle aspiration and a core needle biopsy for a breast mass, can we code both procedures?

Answer: For Medicare, and potentially other payers as well, you should not report a fine needle aspiration (FNA) and core needle biopsy from the same breast mass.

Medicare's Correct Coding Initiative (CCI) restricts when you can get paid for the following codes FNA codes:

• 10021 -- Fine needle aspiration; without imaging guidance
• 10022 -- ... with imaging guidance.
• These two FNA codes are column 2 (component) codes for the following core needle biopsy codes:
• 19100 -- Biopsy of breast; percutaneous needle core, not using imaging guidance (separate procedure)
• 19101 -- ... open incisional
• 19102 -- ... percutaneous, needle core, using imaging guidance
• 19103 -- ... percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance.

If the surgeon provides documentation that the FNA and core needle biopsy are for separate sites (separate lesions or breast masses), you can code both services. In that case, you would need to override the CCI edit pair by appending modifier 59 (Distinct procedural service) to the FNA code.