General Surgery Coding Alert

Question: If the surgeon performs a breast biopsy, and if frozen section comes back positive, also performs a mastectomy, can you bill for both procedures? If so, will I need modifiers?

Virginia Subscriber

Answer: You can report both the biopsy and mastectomy,as long as the results of the biopsy prompted the mastectomy (for instance, if biopsy shows malignancy).

Many biopsy codes are bundled with lumpectomy and mastectomy codes in the national Correct Coding Initiative (CCI). But this does not mean they cannot be billed together: The CCI edits do not apply when the biopsy is diagnostic (that is, the biopsy leads to the decision to perform the larger procedure)

If the results of a biopsy are positive, for example, the surgeon may then perform a lumpectomy or mastectomy to remove malignant tissue. In such a case, the biopsy is not included in the lumpectomy or mastectomy. You would report the biopsy separately.

But, if the surgeon plans to remove a malignant mass but wants a confirmatory biopsy, the confirmatory biopsy is a component of the larger procedure. You would not bill separately for the biopsy.

Note that when you report a separate biopsy with lumpectomy or mastectomy, you should append modifier 59 (Distinct procedural service) to the appropriate biopsy code. This should alert the payer that the biopsy was diagnostic rather than confirmatory, and therefore not included in the more extensive excision.

-- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program.