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FNA and Core needle biopsy

  1. Default FNA and Core needle biopsy
    Medical Coding Books
    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.

  2. Default
    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.

  3. Default
    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.
    Anthony McCallum, CPC, CIRCC, CPC-I, CCS

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