General Surgery Coding Alert

Needle size can help you make the choice between aspiration and biopsy

Coding a breast biopsy often means coding for more than just a breast biopsy. To be sure that you haven't overlooked any reportable procedures, look to this handy checklist. Identify the Primary Procedure When the surgeon performs breast biopsy through the skin using a needle, scalpel, or rotating biopsy device, you should select from among six codes:

10021 - Fine needle aspiration; without imaging guidance

10022 - ... with imaging guidance

19100 - Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)

19101 - ... open incisional

19102 - ... percutaneous, needle core, using imaging guidance

19103 - ... percutaneous, automated vacuum-assisted or rotating biopsy device, using imaging guidance. Distinguish Aspiration From Biopsy To determine whether you should report fine needle aspiration (FNA: 10021-10022) or percutaneous needle biopsy (PNB: 19100-19103), consider two points:

1. Needle size: "A percutaneous needle is much larger than a fine needle," says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist in Brick, N.J.

In FNA, the physician uses a fine-gauge needle (from 18 to 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. The surgeon may make several passes to obtain an adequate tissue specimen.

PNB, in contrast, involves a single insertion to remove a "core" sample of tissue from the lesion.

2. Specimen type. A fine needle takes out an "aspirate," which is typically a mixture of fluid and cells that the surgeon sends for analysis, Cobuzzi says. "A percutaneous needle is larger and takes out tissue in the mass's core," she says.

Remember: Open incisional biopsy (19101) is distinct from FNA or PNB because the surgeon would not use a needle to collect the specimen.

Report FNA Evaluation Separately If the surgeon checks an FNA under the microscope to ensure he has an adequate sample, you should report 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) in addition to 10021 or 10022, says Melanie Witt, RN, MA, CPC, a surgical coding expert based in Fredericksburg, Va. The surgeon then normally sends the cells to the pathologist for evaluation. The lab will report its service separately using 88173, ... interpretation and report. Don't Forget Imaging Guidance You can report imaging guidance separately for procedures 10022, 19102 and 19103 if the surgeon supervises and interprets the results.

Choose from among the following codes, depending on whether the surgeon selects fluoroscopic, computed tomography, magnetic resonance or ultrasonic guidance:
76003 - Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)

76360 - Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological [...]