Pathology/Lab Coding Alert

Question: Our pathologist extracted a fine-needle aspiration specimen from a breast lesion and examined the aspirate. The surgeon decided to perform a needle-core biopsy of the same lesion later in the day. Although Medicare paid for the pathologist’s FNA exam and breast biopsy exam, Medicare denied the FNA procurement charge. Why?


Oregon Subscriber


Answer: Presumably, your charges included at least the following codes: 10021 (Fine needle aspiration; without imaging guidance) for the pathologist’s FNA procurement, 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report) for the FNA interpretation, and 88305 (Level IV--Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins) for the biopsy exam. The surgeon would have billed something like 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]) for the later biopsy.
 
Medicare may deny the FNA procurement charge because the patient underwent a more extensive diagnostic surgical procedure at the same site on the same day. The National Correct Coding Initiative edits bundle FNA with many biopsy procedures under the policy of “sequential procedures.” This policy states that when a physician performs a second procedure because the initial procedure did not successfully accomplish a medically necessary service, you should only report the CPT Code for one procedure, generally the more invasive service.

Even if the patient has an FNA and a biopsy at the same site, the pathologist can still report the FNA specimen exam. Although NCCI bundles FNA procurement with many biopsy codes, it does not bundle FNA pathology examination codes 88172 and 88173 with biopsies. That means you should get paid for the pathologist’s FNA specimen exam, even though you won’t get paid for taking the specimen on the same day as a biopsy.