Internal Medicine Coding Alert

Published on Wed Sep 06, 2006 PDF

Question: We report a fine needle aspiration for a thyroid biopsy with codes 10021 or 10022. However, I've been told that there is another code we can use for this procedure. Is that true? And if so, what is the code?


Florida Subscriber

Answer: Physicians now perform many of their thyroid biopsies with fine needle aspiration, making 10021 (Fine needle aspiration; without imaging guidance) or 10022 (... with imaging guidance) the correct code choice.

Physicians can also perform thyroid biopsies with a percutaneous core needle (60100, Biopsy thyroid, percutaneous core needle), but this procedure is rare; codes 10021 and 10022 have generally replaced 60100. The physician's documentation should clearly indicate which biopsy method he used, and you should choose the code accordingly.

Be sure to choose code 10021 or 10022 based on whether the physician uses ultrasound to guide the biopsy. If your internist performs the biopsy in the office and uses ultrasound, you should also report a separate radiology code, such as 76942 (Ultrasonic guidance for needle placement, imaging supervision and interpretation).

If the physician performs the procedure at a hospital, a radiologist or other practitioner may perform the ultrasound service. In this case, your internist may only be able to bill for the biopsy.