General Surgery Coding Alert

Answer: The answer depends on whether the two procedures are from the same site on the thyroid, or if, for example, one is from the left lobe and one from the right lobe.

 

If the procedures are from different sites, you should list the fine needle aspiration (FNA) as 10021 (Fine needle aspiration; without imaging guidance) or 10022 (… with imaging guidance), depending on whether the FNA was an image-guided procedure. For the biopsy, you should list 60100 (Biopsy thyroid, percutaneous core needle).

 

Override: Because the Correct Coding Initiative (CCI) edits bundle these codes, you’ll need to append modifier 59 (Distinct procedural service) to the column 2 code, which is the FNA. Remember, you can override the edit pair only if the procedures are at different sites or sessions, and you’ll need to document medical necessity for the procedures.

 

Caution: If the surgeon performs the biopsy from the same site because the FNA was inadequate, you should report only the biopsy, according to Medicare instruction:

 

“For example, if a fine needle aspiration of the thyroid (CPT® code 10021) is unsuccessful and is followed at the same patient encounter by a percutaneous core needle biopsy of the thyroid (CPT® code 60100), only CPT® code 60100 may be reported. Therefore, CPT® code 10021 is not separately reportable with CPT® code 60100.”

 

This statement is available at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/ncci_correspondence_language_manual.pdf