General Surgery Coding Alert

Pay special heed to multiple-lesion guidance.

Coding thyroid fine needle aspiration (FNA) cases can present some potential pitfalls for your surgical practice.

Let our experts boost your coding know-how by considering case variations such as image guidance, laterality, and the number of “passes,” in light of statutory guidance from Medicare’s National Correct Coding Initiative (NCCI).

Case 1: Guidance, Lesion(s) Focus Code Selection

The surgeon performs an FNA of a right thyroid nodule, plus an FNA of a nodule of the right thyroid isthmus — both using ultrasound (US) guidance.

Because the case documents US guidance, you should turn to the code family of 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion).

Other guidance options: CPT^® provides the following different code families for other guidance methods:

• 10007 (Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion)
• 10009 (Fine needle aspiration biopsy, including CT guidance; first lesion)
• 10011 (Fine needle aspiration biopsy, including MR guidance; first lesion)

If the surgeon does not document any imaging guidance with the FNA procedure, you’ll turn to 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion).

Count lesions: When reporting FNAs, keep a count of lesions so that you can report the correct codes and the correct number of units. For each of the preceding codes that describes “first lesion,” CPT^® provides a child code for “each additional lesion,” as follows:

• Paired with 10005: +10006 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10007: +10008 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10009: +10010 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10011: +10012 (… each additional lesion (List separately in addition to code for primary procedure))
• Paired with 10021: +10004 (… each additional lesion (List separately in addition to code for primary procedure))

Documentation advice: The op report should identify the location of each lesion that the surgeon samples using an FNA biopsy procedure. If surgeons in your practice use “biopsy” as a universal term to mean they took a specimen sample, you might have a problem. Vague documentation habits can contribute to coding errors involving these needle procedures, says Kelly Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC in Charlotte, North Carolina.

NCCI guidance: Chapter 3, Section K.3, of the NCCI Policy Manual states, “The unit of service for fine needle aspiration biopsy, (CPT^® codes +10004-+10012 and 10021) is the separately identifiable lesion. … A separate unit of service may be reported for a separate aspiration biopsy of a distinct separately identifiable lesion.”

In other words, correctly coding these cases means you need to home in on the number of lesions the surgeon is aspirating. In the case example above, you would report 10005 for the FNA with US guidance on the first lesion (right thyroid lobe) and one unit of add-on code +10006 for the second lesion on the right thyroid isthmus.

Case 2: Beware of ‘Passes’

Surgeons often submit an FNA aspiration to pathology for an intraoperative consultation to ensure that the specimen contains adequate cells for diagnosis. If the pathologist says that the specimen is not adequate, the surgeon will take another FNA “pass” from the same lesion. “Because it’s the same lesion, you should not bill an additional FNA code for the second ‘pass,’” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, CA.

The same section of the NCCI Policy Manual states, “If a physician performs multiple ‘passes’ into the same lesion to obtain multiple specimens, only one unit of service may be reported.”

Another case: Suppose, in the first example, you also read in the op note that the pathology examination states that “Both specimens were inadequate for diagnosis.” Rather than repeating the FNA sampling, the op report documents that the surgeon performs percutaneous needle core biopsies of the right thyroid lobe nodule and the right isthmic nodule at the same encounter as the FNA.

According to the NCCI Policy Manual Chapter 3, Section L.12, “Fine needle aspiration (FNA) biopsies (CPT^® codes +10004- +10012, and 10021) shall not be reported with a biopsy procedure code for the same lesion. 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 physician shall report only one code, either the biopsy code or the FNA code.”

Do this: Because the core biopsy is the more comprehensive procedure that has a higher relative value units (RVUs) than the FNA, you should report the case as two units of 60100 (Biopsy thyroid, percutaneous core needle).

Payer alert: Payers that do not use the NCCI edits and guidance may allow you to bill both the FNA and the core biopsy if the surgeon documents the need for both procedures to obtain a diagnostically viable specimen. You should check with individual payers for their policy on cases like this.

Resource: You can access the latest version of the NCCI Policy Manual at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.