Radiology Coding Alert

Question: How should I code ultrasound guidance for aspiration of a solid lesion with a 22-gauge needle?


Arizona Subscriber

Answer: For guidance of this needle aspiration, report 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation).

You may report 76942 for each lesion biopsied, appending a modifier to subsequent codes, according to your payer guidelines. For example, you may need to append 59 (Distinct procedural service), RT (Right side), and/or LT (Left side).

Caution: Only claim 76942 once per biopsy site, no matter how many passes the physician makes for that lesion.

If your physician also performs the aspiration, report 10022 (Fine needle aspiration; with imaging guidance) in addition to the RS&I code.

Providers can perform fine needle aspiration with any size and type of needle, but most often use a very thin needle to aspirate cells or fluid.

Note: Physicians can and do also perform core biopsies with any size and type of needle including with a 22-gauge needle. Report core biopsies with anatomically specific surgical (non-70000) codes rather than one code for all anatomic locations.
If the service is a core biopsy under imaging guidance, use the correct non-70000 biopsy code in conjunction with the proper RS&I code.

Remember: You should not assume that all procedures that acquire tissue with a 22-gauge needle are aspirations nor should you assume that such procedures are core biopsies. The procedure report must state specifically what the physician did.