General Surgery Coding Alert

Look for three distinguishing features in the op report.

If you’ve ever looked at an op report for a surgical sampling of a thyroid nodule, hepatic lesion, or other site, you might have been lost by the “needle” terminology in the op report.

Maybe it’s not clear if your surgeon performed a fine needle aspiration (FNA) or a percutaneous needle biopsy (PNB) procedure, but you need to know the difference.

Watch out: Choosing the wrong needle sampling code could mean losing hundreds of dollars on a single procedure.

Solution: Use the following three clues to make sure you report the code that most accurately describes your surgeon’s work, and most correctly earns your reimbursement.

Clue: Focus on Accurate Terminology

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 located in Charlotte, North Carolina.

Better way: Although “biopsy” can refer to a tissue or cellular sample, the most concise use of the term refers to procedures that remove a small tissue specimen for diagnosis. These surgical tissue biopsy procedures may be open, laparoscopic, or percutaneous.

“If your surgeons form the habit of using ‘biopsy’ to refer only to tissue biopsy specimens taken using one of these approaches, you’ll know you should turn to a PNB code if the op note shows a needle is involved,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, national director of marketing and revenue management at FasPsych in Omaha, Nebr.

Name the procedure: The best piece of information your surgeons can provide is to put the name of the procedure in the op note. The surgeon knows if she is performing a PNB or an FNA, so she should call it out in the report.

Clue: Check the Specimen and Needle Type

If the op note you’re coding uses fuzzy language, you might find other hints in the report to help you distinguish an FNA from a PNB — notably, needle size and the specimen type.

“A percutaneous needle is much larger than a fine needle,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Specimen: “A fine needle takes out an ‘aspirate,’ which is a sort of fluid sent to the pathologist for analysis,” Cobuzzi says. The fluid contains cellular material for cytology examination.

On the other hand, “a percutaneous needle is larger and takes out tissue in the mass’s core.” She says.

Key terms: You should associate fluid or cell sampling with FNA, and core or tissue sampling with PNB.

Clue: Locate the Appropriate CPT^® Section

FNA and PNB are so different that CPT^® places the procedures in separate sections. FNA has its own codes, which you can find in the “general” surgery section just before the integumentary codes.

Update: CPT^® 2019 introduced big changes to the FNA code section that you need to know. Prior to the changes, you had just two FNA codes to choose from, which you could report once per lesion sampled. The only distinction between the two codes was “with or without” imaging guidance.

As of January 1 this year, you have one deleted, one revised, and nine new codes to describe FNA procedures. The new FNA section provides five families of two codes each. The families vary based on whether and what type of image guidance the surgeon uses. The parent code in each family describes an FNA of the first lesion using that type of guidance, and an add-on code for each additional lesion sampled using the same imaging-guidance method.

Here are the 2019 FNA codes:

• 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion)
• +10004 (… each additional lesion (List separately in addition to code for primary procedure)).
• 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)
• +10006 (… each additional lesion (List separately in addition to code for primary procedure))
• 10007 (Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion)
• +10008 (… each additional lesion (List separately in addition to code for primary procedure))
• 10009 (Fine needle aspiration biopsy, including CT guidance; first lesion)
• +10010 (… each additional lesion (List separately in addition to code for primary procedure))
• 10011 (Fine needle aspiration biopsy, including MR guidance; first lesion)
• +10012 (… each additional lesion (List separately in addition to code for primary procedure)).

How to find PNB codes: Unlike FNA codes, CPT^® doesn’t provide a single section of PNB codes. Instead, you have to look for the anatomic site-specific surgery code.

Example: Your surgeon takes a percutaneous needle biopsy of the liver. The most specific code available for the stand-alone procedure is 47000 (Biopsy of liver, needle; percutaneous)

Speed tip: To quickly locate an exact PNB code, look up “needle biopsy” in CPT^®’s index. Find the anatomical location your surgeon biopsied, such as the thyroid, and, presto, you can look up the specific CPT^® code to ensure it matches the procedure performed and documented. For instance, “thyroid” under the needle biopsy index entry directs you to 60100 (Biopsy thyroid, percutaneous core needle).

Note: Your physician does not have to indicate the word “percutaneous.” Stating “needle biopsy” in the procedure description is sufficient to select a PNB code.

Mistakes could cost you: If you miscode a PNB as an FNA, you stand to lose significant pay. Check out the following example that results in leaving $214 on the table:

For FNA of a liver without imaging guidance (10021), your surgeon could expect payment of $100.19 (2019 Medicare physician fee schedule national facility amount, conversion factor 36.0391). That compares to liver PNB (47000) payment of $314.26 (same parameters).