# thyroid biopsy



## BABS37

Does right lower lobe thyroid biospy with Ultrasound guidance, mid thyroid biopsy with U/G, and right lower thyroid biopsy with U/G count as three separate distinct locations to code 60100 x 3 and 76942 x 3 or do they mean it needs to be left lobe and right lobe to count as separate locations? Any advice would be appreciated!


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## jmcpolin

I worked for some radiologist for about 7 years and everything I ever read said no matter how many biopsies you take you only have 1 thyroid and so you can only bill it once.


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## BABS37

I also worked in radiology for four years and you can bill for separate and distinct lesions biopsied in each lobe of the thyroid if the documentation supports it. In that case, you would bill 60100 twice. If the physicians states he used ultrasound guidance in each of the separate biopsies and it's clearly documented, that can also be billed twice for each separately guided biopsy. If it multiple passes at the same site or different sites but the same lesion, then no, I couldn't code but one biopsy. 

But what I am asking is, does that mean only once in the left lobe of the thyroid and once in the right lobe of the thyroid or does middle and lower right count as two different locations as he documented them as three separate lesions?


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## Lujanwj

This is going to come down to payers policy and their Medically Unlikely Edits.  With that said, CPT clearly states "Biopsy" in the singular form which means, in CPT world, that you code for each biopsy.  Remember, in CPT, code will describe "Biopsy(ies)" if code represents 1 or more biopsies. With that being said, you payer might have an MUE of 1.  I can't find any published MUE's from CMS on 60100.  

As far as the ultrasound, the same will apply.  However, CMS has an MUE of 1.  In this case I would only bill 76942 once.  Be sure that dr is dictating a separate report from the opnote with indications and findings for each radiology code billed.  If not, you can not bill for them.  

Good Luck!


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## BABS37

I found this article on supercoder so I think it's ok to do so? - according to medicare... 

Code DescriptorBiopsy thyroid, percutaneous core needleNotes:
(If imaging guidance is performed, see 76942, 77002, 77012, 77021)

(For fine needle aspiration, use 10021 or 10022)

(For evaluation of fine needle aspirate, see 88172, 88173)Lay Term

Tips
When we perform core biopsies on both thyroid nodes, I report two biopsy codes. But what codes should I report if I perform the biopsies on two nodules in the same lobe? 

Answer
Medicare allows practices to report 60100* (Biopsy thyroid, percutaneous core needle) once per lesion or nodule. You should submit your claim, therefore, by reporting 60100 x 2 to represent the two nodules that you biopsied. If the physician uses ultrasound guidance to pinpoint the biopsy location, you should also report 76942(Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imagingsupervision and interpretation) once for each separate nodule biopsied. You should append modifier -59 (Distinctprocedural service) to indicate that you performed the biopsies on separate and distinct anatomic areas. Because 60100 is a starred procedure, the service includes only the surgical procedure and not any related pre- and postoperative services. If the patient requires a hospital visit for the biopsy, you should report a hospital care code (e.g., 99221-99233) in addition to 60100.


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## Lujanwj

I don't entirely agree with the Supercoder.  Be careful because Supercoder is not Medicare.  They are giving their opinion, much like all of us on this forum.  Unless it's actual documentation from CMS, it's just someones opinion 

In my opinion, this is where Supercoder is wrong:

60100 has a 000 day global which does include Pre/post op care or as they state "hospital visit" on that same date of service.  000 global indicates there is E/M included in and reimbursed for in the code.  This is why you must justify mod-25 on a procedure with global of 000 or 010.  Mod -25 says: We know this code has a global E/M but Dr did "significant, separately identifiable E/M" from the global E/M reimbursed for in the code.  

Billing 99221 series code would only be billed if the patient was admitting or in an Inpatient status, and you'd still have to justify Modifier -25. 

Billing 76942 more than once.  I'm not sure why Supercoder address medicare allowances/MUE's for the biopsy but not for the ultrasound.  I'm seeing 1 MUE but I guess you can appeal and show medical necessity.  Just be ready for a denial based on CMS' MUE's

Just my 2 cents


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## BABS37

I agree, supercoder isn't the brightest coding tool available and I would rather go with Encoder but it was the only one available to our office for the available funds our department had. And yes,  I would say it didn't exactly nail the inpatient stuff on the head by any means- I think they left out some info or I did when I copied the article- I was only intending to point out the verbiage from the thyroid biospy so maybe that was my fault and not supercoder. Anyhow, I have found several medicare and non-medicare and small insurance guidelines along with ACR and other accredited coding resources we are all probably familiar with. According to my doctors report, he only 'documented ultrasound guidance for one biopsy and failed to mention it again when he documented his other two biopsies so that was only coded once. I know the example below from American College of Radiology is referring to two breast nodules, which it seems as though they are taken from the same breast- as we have a right and left breast so wouldn't that technically be the same as a right and left lobe of the thyroid? All in a matter of opinion, of course, just like the rest of the articles below. I'm prepared to follow up with a denial if that be the case as medicare usually always requests supporting documentation and I'll have that. And come to think of it, I haven't even checked to see if the patient has medicare or not. I was just simply wanting to know the opinions of other coders on how they have coded situations such as this and it's a learning experience. So thank you for your opinion. It was much appreciated.

Version 15.3 of the CMS National Correct Coding Policy, Chapter 9, states in the Medically Unlikely Edits section: 

CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not the number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations. 

In the above statement, CMS allows one payment per encounter for needle placement guidance. 

Medicare. To be in accordance with Medicare policy, code only one needle placement, according to the National Correct Coding Initiative (NCCI) guidelines. Also, remember this applies only to codes 76942, 77002, 77003, 77012, and 77021. Other guidance codes, such as mammographic (77032), stereotactic (77031), and catheter placement (75989) can be coded and modified with the -59 modifier as necessary for all payers. 

Non-Medicare . For commercial insurance, consider applying modifier -59 or -76 if documentation supports the biopsy guidance procedures when reporting 76942, 77002, 77003, 77012, and 77021 for multiple lesions on the same encounter. 

When multiple procedures are performed for different patient encounters on the same day, apply the appropriate modifier (-59) to distinguish payment for different encounters, including those involving Medicare patients. 

Coding scenarios. Ultrasound-guided needle breast biopsy and stereotactic-guided needle breast biopsy: Your code for this ultrasound scenario will be 76942. Use 77031 with the -59 modifier on the stereotactic biopsy for all payers. 

Two stereotactic needle breast biopsies: This concept would be 77031 and 77031 with the appropriate modifier -59, -76, -LT, or -RT (depending on carrier specifics) on the second guidance procedure code 77031.
Society instructions create confusion
CMS instructions state that billing for imaging guidance must be per encounter and not per lesion. However, society guidelines have always defined imaging guidance as per lesion or anatomical area involved, which has created confusion. 

American Medical Association: Code 76942 should be per distinct lesion that requires separate needle placement (CPT Assistant, April 2005, page 16). 

American College of Radiology: In describing ultrasound guidance for needle aspiration of two breast lesions (76942), ultrasonic guidance for needle placement is also reported twice because two lesions, one at the 2 o'clock position and the other at the 11 o'clock position, were treated. Note, it is the number of lesions sampled, and not the number of punctures, that is the determining factor on how many codes to report (Clinical Examples in Radiology, Fall 2008, page 3). 

The Society of Interventional Radiology: The 2009 Coding Guidebook does not provide an opinion for how to code. “CMS has enacted MUEs (Medically Unlikely Edits), which limit the reporting of needle placement imaging guidance codes to once per session. The ACR and SIR are currently reviewing this issue as the code descriptors for the imaging guidance codes clearly state ‘biopsy' not ‘biopsies.' We will be exploring these edits with CMS to determine if they are appropriate or if the allowed MUE frequency unit should be increased,” it states. 

This creates a bit of confusion, for now, as we must adhere to the CMS guideline and bill all of the listed imaging guidance codes only once per encounter for Medicare patients. If the specialty societies are successful in convincing CMS to increase the MUE unit frequency, then the coding can be revised. 

As a reminder, charges that are denied for units in excess of the MUEs may not be billed to the beneficiary. The Advance Beneficiary Notice of Noncoverage (ABN) form cannot be used to seek payment from the beneficiary. s,


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## Pam Brooks

babierman said:


> I agree, supercoder isn't the brightest coding tool available and I would rather go with Encoder but it was the only one available to our office for the available funds our department had.


 
I agree...you have to be careful with these software packages. One of the other reasons we didn't go with Supercoder, is that they outsource their customer service to India. By principle, I chose not to use them.

It always pays to check with your local contractor, and payer guidelines, but it is a lot of work, but the coding software programs do point you in somewhat of the correct direction as a starting point.


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