General Surgery Coding Alert

To be sure that you've mastered breast biopsy coding, test your knowledge against the following scenarios.
 
Scenario 1: Under fluoroscopic guidance, the surgeon makes a small incision and removes tissue from two separate breast lesions using a needle core. One lesion is on the right breast, the second is on the left breast.
 
At the same time, the surgeon places a localization clip in each breast to identify the site of the lesion. The surgeon closes the surgical wound and sends the samples to pathology for analysis. This occurs in a facility setting.

How to report it: In this case, the primary procedure is 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) because the surgeon used the needle core to collect the tissue sample. Because the surgeon took samples from both breasts, you should also apply modifier 50 (Bilateral procedure).

Report fluoroscopic guidance using 76003-26 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]; Professional component). You may also separately report the imaging guidance for placement of the localization clips using +19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy [list separately in addition to code for primary procedure]).

Closure of the surgical wound is included in the primary procedure.

Scenario 2: Using a 22-gauge needle under computed tomography (CT) guidance, the surgeon aspirates material from a lesion on the patient's left breast. The surgeon examines the specimen to be sure he has collected sufficient material for further pathology evaluation. The procedure takes place in a facility setting.

How to report it: The surgeon's use of a fine-gauge needle under guidance with collection of aspirant should clue you in that the primary procedure is 10022 (Fine needle aspiration; with imaging guidance).

You may report the CT guidance separately using 76360-26 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation).

You can also report the surgeon's analysis of the aspirant sample using 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]).

Scenario 3: The surgeon uses a scalpel to remove a small amount to tissue from a lesion of the right breast. The surgeon closes the surgical wound and sends the tissue sample to pathology for analysis.

How to report it: The surgeon performed a simple open incisional biopsy (19101, Biopsy of breast; open, incisional). Closure of the surgical wound is included in the biopsy.