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Thread: FNA vs biopsy

  1. #1


    AAPC: Back to School
    Not necessarily. I am assuming you are billing for the physician however if you are not please disregard what I am about to say......

    Excerpt from 2009 Medlearn IR Coder- "As a rule of thumb: an aspirational biopsy sample is sent to pathology for cytologic examination; a core biopsy sample is sent to pathology for histological examination."

    If you are billing for the physician's services then it does not matter if there was a pathology &/or cytology report provided since it would not reflect the way the physician bills for his services. If he or she says it was a biopsy in their report then it would be coded as such unless they state otherwise (eg. biopsy was attempted however only fluid could be obtained and was submitted. (This would change the procedure to an aspiration)).

    And how can I recite this lovely information??? Because I've in your position and had many physicians point it out to me when I used to question them!!!! Of course, it did not stop me from still questioning them about other things! It's the best way to learn.....
    Hope that helps a little. And again, if you are not billing for the physician just ignore me completely!
    Anita W, CIRCC, RCC, CPMA, CPC

  2. #2
    Join Date
    Apr 2007
    Albany, New York


    Please refer to the CPT Assistant below: (A FNA can be utilized to obtain
    fluid or tissue)



    A biopsy was performed by our radiologist using the fine needle aspiration technique. The intent of the procedure was to obtain a biopsy. Should this be reported using a biopsy code or the fine needle aspiration code?

    AMA Comment

    From a CPT coding perspective, the fine needle aspiration codes (88170, 88171) are intended to report the aspiration of fluid or tissue through a long slender needle, followed by a cytological examination of the cells which are obtained. This is in contrast to a biopsy, where a small piece of tissue is taken and examined for histologic architecture. The method used for obtaining a specimen depends on the clinical situation and clinical factors (eg, suspected diagnosis, location of lesion). The physician should report based on the method used to obtain the specimen.

    CPT Assistant © Copyright 1990–2009 American Medical Association. All Rights Reserved
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3


    So basically, you are trying to determine whether you have 10022 or a 32405? Is that correct?

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