Oncology & Hematology Coding Alert

Ambiguous statements by Medicare in the 2003 Physician Fee Schedule regarding the use of modifiers with bone marrow biopsy and aspiration procedures mean that oncology coders are still singing the bundling blues. Now, physician work RVUs for 38220 (Bone marrow; aspiration only) are 1.08 with a nonfacility practice expense rate of 4.64, and 0.43 in the facility. For 38221 (... biopsy, needle or trocar), they are 1.37 with a nonfacility practice rate expense of 4.79, and 0.54 in the facility. The new year leaves the two codes effectively bundled. "If you do a biopsy, then you also did an aspiration, because that's the only way you're going to get the sample for the biopsy," says Carolyn M. Davis, CMA, CPC, CCP, CCS-P, CPHT, TMC, the billing supervisor for Oncology Hematology West in Papillion, Neb., and a professional coding and continuing education instructor (through AAPC) at Iowa Western Community College. Davis says that the only way you can get them paid separately is if you can show that the procedure involved separate or bilateral sites. Modifier -51 Is Like Area 51 Hard to Locate In the 2003 Fee Schedule , CMS (agreeing with AMA) says that when a bone marrow biopsy and aspiration are performed through the same incision, you should report both 38220 and 38221 with modifier -51 (Multiple procedures) appended. (Editor's note: See 67 Fed. Reg. 79992.)

But CMS'buy-in to the modifier -51 strategy defies the logic of CPT 2003, Davis thinks. "Because the definition of 38221 in the 2003 CPT code book now includes aspiration and biopsy, it's going to be hard to use the -51 modifier," she says.

This scenario could occur if a pathologist does the actual procedure, Davis suggests. After performing an initial aspiration and running a slide mid-procedure, the physician might go to a different area in the same site and pull a biopsy of the bone marrow and run that study. You can then use modifier -51 with 38220 and 38221, Davis says, because you can prove that the pathologist did two different procedures through the same incision.

But, Davis cautions, this is an unusual example, and you'd want to use extreme care with your documentation. The 38220 would refer strictly to the aspiration that the physician looked at, while 38221 would refer to the biopsy taken in the secondary procedure. Actual payment will probably depend on local Medicare carrier policy, she says. Last Word on Modifiers -50 and -59 CMS'guidance in the fee schedule doesn't supercede the use of modifier -50 (Bilateral procedure) for a standard bilateral bone marrow biopsy, says Jeanne Potter, CCS-P, CPC, the state reimbursement specialist with [...]