Radiology Coding Alert

Question: How should our practice report a CT-guided needle biopsy of an adrenal mass?

Iowa Subscriber
Answer: Using current biopsy techniques, the radiologist  would most likely perform a core-needle biopsy in this case. This would be reported with 49180* (biopsy, abdominal or retroperitoneal mass, percutaneous needle) and radiology supervision and interpretation (RS&I) code 76360 (computerized tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation).
 
In unusual circumstances, sampling or fluid collection may be performed, which would indicate fine-needle aspiration. This would be reported with 88171 (fine needle aspiration; deep tissue under radiological guidance). This latter procedure code should only be used if a core of tissue (of whatever size) was not obtained. Notes following this code description in CPT 2001 direct coders also to assign the appropriate RS&I code. In this example, 76360 would be assigned. Alternatively, ultrasound (76942, ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) or fluoroscopy (76003, fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) could be used.
 
Coders should be aware that the fine-needle aspiration code will be changed in CPT 2002 (see page 82). The new codes are 10021 (fine needle aspiration; without imaging guidance) and 10022 ( with imaging guidance).