Orthopedic Coding Alert

Question: I am having trouble getting paid when a biopsy is done in the same operative session as a tumor excision that was read by the pathologist prior to excising the tumor. An oncologist in our practice does this frequently. Ive had a few of these paid since I discovered the following in the national Correct Coding Initiative (CCI) manual: If the decision to perform the more comprehensive procedure is based on the biopsy result, i.e., the biopsy is diagnostic, then the biopsy service may be reported separately. But now Im getting a denial from a major carrier, stating that their policy guidelines do not allow this. Are there any Medicare guidelines or other tools that might help?

Florida Subscriber

Answer: It is not unusual for a biopsy to be done and sent to the pathologist for interpretation during the operative session. It comes back as positive, so the tumor is excised. In this instance, you can code for both. This is often done by general surgeons with breast biopsies. If the frozen section comes back cancerous, the surgeons will perform a mastectomy.

However, if your surgeon had planned prior to the surgery to remove the tumor, you cannot bill for the biopsy separately. If you are doing the biopsy to determine whether you want to excise the tumor, you would bill for it.