Question: How should we report a CT-guided needle adrenal mass biopsy?
Missouri Subscriber
Answer: If the physician performs a core-needle biopsy, you should report 49180 (Biopsy, abdominal or retroperitoneal mass, percutaneous needle) with 76360 (Computerized tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation).
In unusual circumstances, the physician might collect fluid, which would warrant a fine-needle aspiration code. If she uses imaging guidance, report 10022 (Fine needle aspiration; with imaging guidance) along with an imaging guidance code.
If the physician performs the aspiration without radiologic guidance, choose 10021 (... without imaging guidance).
Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
