Ob-Gyn Coding Alert

If there's more than 1 biopsy, look to 50, 51 and 59.

If you're constantly battling payers over the reduction of reimbursements and denials of second procedures along with breast lesion excisions or breast biopsies, this expert coding advice is for you.

In most cases, if an ob-gyn performs a breast biopsy, he will only extract a small portion of the lesion. For this reason, you're not likely to report additional codes for wound closure or skin grafts, but you might report more than one biopsy per breast or multiple biopsies in both breasts, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

You may also find that you report adjunct procedures such as 1) placement of a clip to identify the site if the biopsy should come back as malignant or 2) radiologic imaging procedures.

What to expect: You'll receive full reimbursement for the first biopsy, but payers will discount the amounts for any additional surgical procedures. Payers reimburse only for the intraoperative portion for additional biopsies and procedures. But you can expect full payment for at least the professional component for a radiologic imaging procedure. If the payer uses Medicare guidelines, however, you won't be reimbursed separately for any anesthesia service including conscious sedation, and all supplies will be included as well..

Ask 2 Questions for Needle Biopsies

When an ob-gyn performs a biopsy through the skin using a needle, scalpel or rotating biopsy device, you'll have six code choices to choose from:

• 10021 -- Fine needle aspiration; without imaging guidance
• 10022 -- ... with imaging guidance
• 19100 -- Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)
• 19101 -- ... open incisional
• 19102 -- ... percutaneous, needle core, using imaging guidance
• 19103 -- ... percutaneous, automated vacuum-assisted or rotating biopsy device, using imaging guidance.

If the ob-gyn performs the biopsy using a needle, you should ask yourself two questions: First, did he incise the skin prior to inserting the needle into the lesion? Second, was the specimen collected using an imaging guidance? The answers will help you pick appropriately between a fine needle and needle core biopsy. An open incisional biopsy would not involve use of a needle to collect the specimen.

Know your terms: "Percutaneous" means that a needle is inserted via the skin into an identified lesion. It does not involve making an incision or sutures to close the skin following the removal of the specimen, Witt says.

How to Report More Than 1 Biopsy

If the ob-gyn performs more than one biopsy in a different location, you would reflect this by using modifier 50 (Bilateral procedure), modifier 51 (Multiple procedures), or modifier 59 (Distinct procedural service).

The challenge is that you won't find a standard protocol for submitting claims for bilateral procedures.

Example 1: The ob-gyn performs a single percutaneous biopsy with imaging guidance on a lesion of both the right and left breast. You should report 19102-50 (the CPT standard) with one of the following if performed and documented:

• 77031-26-Stereotactic localization guidance for breast biopsy or needle placement (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation
• 77032-26-Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation
• 77012-26-Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation
• 77021-26-Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation
• 76942-26-Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

You don't need a multiple-procedure modifier for the radiologic code, but you will need to append modifier -26 (Professional component) unless your practice used its own equipment.

Example 2: The physician also placed a metallic localization clip into each lesion at the time of the biopsy. You should change the coding in the previous example to 19102-50, +19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration [list separately in addition to code for primary procedure]) and 19295 again, plus any billable radiologic procedure.

Notice how you don't need modifier -51 on 19295. The reason is that 19295 is a CPT "add-on" code that never takes a modifier. You should report it for each clip the ob-gyn places.

Don't Miss Out on Modifier 59

You can report modifier 59, but you should only do so when the payer bundles the additional procedures and you have met the requirements for using this modifier.

Example: Your payer may bundle preoperative placement of a needle localization wire (19290) into the code for a fine needle aspiration with imaging (10022). If the ob-gyn can make a case that he placed the wire on the same service date but at a different session, you can report the two procedures as 19290-59 and 10022-51. Keep in mind that the RVUs for the needle placement are higher than the RVUs for the fine needle aspiration in the outpatient setting (but not the inpatient setting), hence the placement code, which is normally bundled, goes first.