FNA and Core needle biopsy


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Both core needle and FNA is done in same lesion should i code both biopsy or only core biopsy please clarify

Clinical history: 51-year-old male HIV positive with
lymphadenopathy and multiple splenic lesions.. Request is made
for CT guided biopsy.

Technique: Initially the procedure was discussed with the patient
including risks, benefits and alternatives. Risks discussed
included but were not limited to bleeding, infection,
pneumothorax, intra-abdominal organ and vascular injury. The
patient understood, asked appropriate questions \T\ signed
informed written consent.

Preliminary CT was performed with the patient in supine position
and a grid to mark a site for the biopsy. A left upper quadrant
site was marked, prepped and draped in the usual sterile fashion.
The area was locally anesthetized with one percent lidocaine.
Using CT guidance, a 19/20 gauge coaxial core biopsy needle was
advanced, positioned with the tip within a splenic lesion. FNA
was performed using a 21-gauge needle. Biopsy was then performed
with the 20-gauge coaxial core biopsy needle. A total of two
passes were made. Specimen was placed in formalin and RPMI.
Specimen was given to Dr. of Pathology at the time of
procedure, confirming lesional tissue. At the end of the
procedure a sterile dressing was applied. The patient tolerated
the procedure well, and left the department in stable condition.
No immediate complications.

Impression: CT guided core biopsy of splenic lesion with 19/20
gauge coaxial core biopsy system as well as FNA with a 21-gauge
needle. Specimen given to Pathology at time of procedure.


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The physician is in the same site, it seems. You can't use F-Needle if there is another code available thats more specific to that Bx he performed. I would stick with the coxial needle code. If its 2 different areas then I would say FN would be charged with also with a 59 modifier.


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The CCI Manual (located on CMS website) Chapter 6 Version 13.3, page 11, item 17.
"FNA should not be reported w/ another bx procedure code for the same lesion unless one specimen is inadequate for diagnosis...If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of bx is subsequently performed at the same encounter, the other bx procedure may also be reported with an NCCI-associated modifier.

Hope this helps.