General Surgery Coding Alert

Question: Our surgeon performed a fine needle aspiration followed by an excision of a 1.5 cm soft tissue mass of the face. Can we bill both the 10021 and the 21011 services?

Utah Subscriber

Answer: No, you should not bill 10021 (Fine needle aspiration; without imaging guidance) and 21011 (Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm) for the two procedures directed at the same mass. Instead, you should report only the most extensive procedure: 21011.

Here's why: CMS bundles FNA and soft tissue tumor codes under the "sequential procedures" policy of the Correct Coding Initiative (CCI). The guidance states, "On occasions where it is necessary that the same provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported."

CCI lists FNA 10021 as a column 2 code with 21011 indicating that you should not separately bill an FNA when the surgeon follows with another soft tissue tumor excision procedure at the same site

Exception: If the surgeon provides documentation that the FNA and soft tissue tumor excision are for separate sites, you can code both services. In that case, you would need to override the CCI edit pair by appending modifier 59 (Distinct procedural service) to the FNA code. Your case does not meet the criteria to "unbundle" the edit pair using modifier 59.