This commentary is a summary prepared by McKesson’s Revenue Management Solutions division and highlights certain changes, but not all changes, in 2011 CPT® codes relating to the specialty of emergency medicine. This commentary does not supplant the American Medical Association’s (AMA) current listing of CPT codes, its documentation in the annual CPT Changes publications and other related publications from the AMA, which is the authoritative source for information about CPT codes. Please refer to your 2011 CPT Code Book, annual CPT Changes publications, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.
CPT is a registered trademark of the American Medical Association (AMA). The AMA is the owner of all copyright, trademark and other rights to CPT and its updates.
Documentation and Coding Image-Guided Percutaneous Needle Biopsy and Fine Needle Aspiration
This article details elements that can be included in the dictated report to support the procedure being performed and assist coders in the appropriate CPT® assignment. Including specific information will prevent returns for additional information (See bolded italics).
Image guidance is used to identify the area to be sampled and ensure that the needle is placed in the correct location for the biopsy or aspiration. Include a detailed description of the guidance procedure used for needle localization required to complete the procedure.
The corresponding site-specific percutaneous needle biopsy CPT would be assigned when obtaining a tissue sample, which is sent to pathology for histologic evaluation. A core of tissue may be obtained with even the smallest needles; therefore, needle size is not the indicator for assignment of percutaneous needle biopsy CPTs.
The above needle biopsy codes include a parenthetical note in the CPT manual with an instruction, “For fine needle aspiration, use 10021 or 10022”; therefore, it is important to distinguish that the procedure is a tissue biopsy versus a cellular or fluid sample.
Fine Needle Aspiration (FNA) is a cellular sample or fluid sample obtained and sent to pathology for cytologic evaluation. CPT 10022 is reported for image-guided FNA and is not site specific. To prevent any confusion, it is important to state “fine needle aspiration” when this procedure is performed. Any size needle can be used to obtain the sample; however, usually a fine, thin needle is used to aspirate the sample.
If the intent is to biopsy one organ (e.g., left kidney to evaluate kidney disease), only one biopsy would be reported regardless of the number of samples obtained from the left kidney. Likewise, if biopsy of the right and left kidney was performed, one biopsy may be reported for each kidney (50020-RT, 50200-LT). One biopsy may be billed per mass, lesion or nodule regardless of the number of samples obtained. If multiple separate masses, lesions or nodules are biopsied, it is important to provide the specific location of each to support reporting one biopsy per separate mass, lesion or nodule.
Per the Centers of Medicare and Medicaid Services’ (CMS) National Correct Coding Initiative (NCCI), “Fine needle aspiration (FNA) (CPT codes 10021, 10022) should not be reported with another biopsy code for the same lesion unless one specimen is inadequate for diagnosis. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. 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 biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the other biopsy procedure may also be reported with an NCCI-associated modifier.” If applicable, include these details in the procedure description.
Complete documentation will promote accurate CPT assignment and ensure appropriate reimbursement in a timely manner.
National Correct Coding Initiative Policy Manual for Medicare Services
ACR Radiology Coding Source, Nov.-Dec. 2005
Society of Interventional Radiology, Interventional Radiology Coding Users’ Guide, page 74
Myra L. Blankenship, CPC, CIRCC
National Coding Manager, Radiology
McKesson Revenue Management Solutions
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