General Surgery Coding Alert

Question: Our provider performed a bilateral ultrasound (US)-guided fine needle aspiration (FNA) biopsy of the breasts. The operative report goes into full detail for aspiration of the right breast, but only indicates that “a similar procedure was performed on the left side.” Is this enough documentation to support a bilateral procedure? If so, how should I report the codes?

Codify Subscriber

Answer: This kind of verbiage is not unusual for a US-guided FNA biopsy report that indicates the surgeon performed a duplicate procedure contralaterally. Although the documentation you describe is not ideal, you shouldn’t need an addendum to code the procedure bilaterally. You may want to let your provider know that best dictation practices include the details specific to each side — in particular for malpractice defense.

As for the procedure coding, remember that 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion) has a medically unlikely edit (MUE) of 1. This means that you may report only one unit of 10005 on any given date of service (DOS). Reporting 10005 separately with modifiers LT (Left side) and RT (Right side) is inappropriate, and the payer will deny the service.

Consider the following CPT^® Assistant guidelines:

• “Codes 10004-10012 and 10021 may be reported only once per lesion sampled in a single session. When more than one FNA biopsy is performed on separate lesions at the same session, on the same day, and using the same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s).”

Based on these instructions, you should report 10005 with modifier RT for the first lesion of the right breast and 10006 (… each additional lesion (List separately in addition to code for primary procedure)) with modifier LT for the second lesion of the left breast.