Outpatient Facility Coding Alert

You Be the Coder:

Decipher This Biopsy Scenario

Published on Thu Jan 11, 2018

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Question: What CPT^® code should I report for a "fine needle" prostate biopsy procedure?

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Answer: When using a needle to sample the prostate gland, a surgeon might take one of two paths. First, he might take a prostate needle biopsy (PNB) specimen - a small piece of tissue extracted through a hollow-core needle. Or, he might take a fine needle aspiration (FNA) specimen - a fluid "aspirate" of cells extracted from the organ through a small needle.

Depending upon the needle procedure, you would report one of the following codes:

55700 (Biopsy, prostate; needle or punch, single or multiple, any approach)
10021 (Fine needle aspiration; without imaging guidance)
10022 (... with imaging guidance).

To help you figure out which procedure your surgeon performed, look for the following items in the op report:

Approach: For a PNB, a surgeon will almost always do a transrectal or perineal approach to obtain a needle prostate biopsy for analysis.
Specimen: You should associate fluid or cell sampling with FNA and core or tissue sampling with PNB. See the surgeon's description of the specimen to help you choose the right code. Also note that the pathology report can help clarify the type of specimen, and you should be waiting for that report before assigning diagnoses anyway.
Needle size: A percutaneous needle, which the surgeon uses to extract tissue, is much larger than a fine needle, which the surgeon uses to extract a fluid aspirate.
Payment implications: Missing the proper code for a prostate specimen could result in leaving money on the table - or overcharging for a service that could turn up on audit and require re-payment. Specifically, Medicare's 2018 Outpatient Prospective Payment System (OPPS) rate for 10021 is $310.78, while payment for 55700 is $1,695.57. The Ambulatory Surgical Center (ASC) payment rates are $73.08 and $779.59, respectively, effective January 1, 2018.