General Surgery Coding Alert

Question: Our surgeon performed a fine needle aspiration of a mediastinal mass. During an intraoperative consultation, the pathologist said that the specimen was inadequate due to much contamination with blood cells. For that reason, the surgeon then performed a needle core biopsy of the mass. Can we code for both procedures?

California Subscriber

Answer: You should be able to code both of these procedures in this case. You didn’t mention that your surgeon used imaging guidance, so the correct code for the fine needle aspiration (FNA) would be 10021 (Fine needle aspiration; without imaging guidance). The code for the core needle biopsy is 32405 (Biopsy, lung or mediastinum, percutaneous needle).

Caveat: For Medicare and other payers who follow Correct Coding Initiative (CCI) policies, you should report both services only if the FNA specimen isn’t adequate and therefore there is medical necessity for another type of biopsy. The NCCI Policy Manual gives this rule in Chapter 3, Section L 11 (www.cms.gov/NationalCorrectCodInitEd/ ).

Straight from the source: “Fine needle aspiration (FNA) (CPT^® codes 10021, 10022 [...with imaging guidance]) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the other biopsy procedure code may also be reported with an NCCI-associated modifier.”

Modifier: Because there is a CCI edit pair that bundles 32405 and 10021, you’ll need to append modifier 59 (Distinct procedural service) or other appropriate modifier to 10021.