Orthopedic Coding Alert

Clue: Biopsy depth helps point you to the correct code.

If bone biopsy coding trips you up, looking for three key items --location, procedure, and number -- can steer you toward full reimbursement for these common procedures. Our experts further demystify these procedures with the advices below.

Identify the Right Location

The most crucial component when reporting a bone biopsy is to know how deep your surgeon went. This should be fairly easy to determine from the operative note.

Basic tip: The codes for bone biopsy describe the superficial and deep bones. The superficial bones are the ones that can be felt through the skin and the deep ones lie deeper under the muscles and are not felt easily through the skin. "The ilium, sternum, spinous process, trochanter of femur and ribs are superficial and the bones like humerus, ischium, femur and the vertebral bodies are deep," says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

Example: For a vertebral biopsy, you would look at the spinal location. For an open biopsy in the thoracic vertebrae, you report code 20250 (Biopsy, vertebral body, open; thoracic) and when reporting the same at the cervical or lumbar levels, you report 20251 (Biopsy, vertebral body, open; lumbar or cervical).

Know the Approach

Your surgeon may use a trochar or needle to collect a sample of bone tissue through the skin. In this case, you report code 20220 (Biopsy, bone, trocar, or needle; superficial [eg, ilium, sternum, spinous process, ribs]) or 20225 (Biopsy, bone, trocar, or needle; deep [eg,vertebral body, femur]) depending upon the approached bone being a superficial one or a deep one.

Alternatively, your surgeon may biopsy the bone by exposing it surgically or during an exploration done in an operative attempt to remove the pathology. "In this scenario, the biopsy is only separately reportable when it is used to make an immediate diagnosis and drives the decision to perform the more extensive procedure," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. You report codes 20240 (Biopsy, bone, open; superficial [eg, ilium, sternum, spinous process, ribs, trochanter of femur]) or 20245 (Biopsy, bone, open; deep [eg, humerus, ischium, femur]) depending upon the bone biopsied.

Watch for Multiple Biopsies

Your surgeon may do more than one biopsy. In this case, you will be able to earn payment for each separate approach. You can report the code twice in this situation.

Example: If the surgeon does a biopsy of the vertebral body in the lumbar region and another one in the ischial tuberosity, you can report two units of 20245. Check your payer preferences and append modifiers -50 (Bilateral procedure:.....) , -51 (Multiple procedures:.......), or -59 (Distinct procedural service:.....).

"There would have to be modifiers in this case because you are using the same code twice - possibly -50 for bilateral biopsies (rare), or -51 for two biopsies in two separate locations," says Mallon. "Technically modifier -51 is correct; sadly, payers often deny the second line item as a duplicate. Some payers may require modifier -59 in this scenario. It's best to know you payers' reporting guidelines," says Stout.

Report Both Incision and Excision

"CPT® does not discriminate between the incisional or excisional biopsy procedures," says Mallon. 'Incision' implies that the surgeon made a slit in the involved part and obtained a sample of tissue for biopsy. 'Excision' implies that the lesion was removed and subjected to microscopic examination in the laboratory. You can use the same codes for both.

Capture All Subsequent Procedures

Incisional biopsies are usually diagnostic, and are usually performed in suspected malignant lesions. You will need to read the operative note further to know what was subsequently done in the lesion that was biopsied. Your surgeon may curette, destroy, repair, fix, or excise the lesion based upon the results of the biopsy. A biopsy is hence directive for the next plan of action.

You can report codes for both the biopsy and the procedure that followed the biopsy. Excisional biopsies can be both diagnostic and therapeutic, and are usually chosen when the lesion is expected to be benign. "Under these circumstances, the mass excision code is typically reported," says Stout.

Example: If you read that the biopsy of the tibia was followed by curettage of the lesion, you report 20240 and 27635 (Excision or curettage of bone cyst or benign tumor, tibia or fibula). You can append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 27635.