Wiki 76942 with 19103

[bkerste]

Hi all, need a little help please. I don't have a lot of experience with coding for US guided breast biopsy & wanted to make sure I've got this right. The patient had 2 separate masses in the same area of 1 breast & both were biopsied. I know I bill for each biopsy & clip placement, but I only bill the US guidance (76942) once since it was in the same area of the same breast, correct?

 

[JDACPC]

CPT Assistant March 2010 states one surgical component and one guidance code should be reported for each lesion. However, according to CMS National Correct Coding Policy Manual (Chapter 9), Medicare (and others), only allow ONE guidance code PER ENCOUNTER, not per lesion, number of biopsies, etc. (MC guideline does not apply to stereotactic or mammo guidance, since those codes state "each lesion.")

Having said all that, in your example, if they are in the same area, only code one guidance code. If there were biopsies on RT and LT, or one at 12 o'clock and one at 6 o'clock, I would code twice. Check your major carrier's policies and submit accordingly.

Just a side note, we (professional side) are seeing denials (MC, Aetna, and others) on the clip placement as of 2013 because it's now deemed "technical component only." We have been told by a national auditing company to continue to bill the 19295 for 2013, without expectation of payment, and that there are new bundled codes in store for 2014.

Hope that helps!

 

[bkerste]

Thanks! That's exactly what I needed The second lesion was behind the first so it's definitely a shared area without major repositioning.

Also, thank you for sharing where you found the information. I like knowing where I can go to find the info in case someone at my office or one of the physicians disagrees.

I'll try for the 19295 & see what happens. If they are really going to begin bundling it with the actual biopsy, hopefully they will also allow a slight increase in reimbursement for the biopsy code. I'm not going to hold my breath, but that would only be fair.