General Surgery Coding Alert

Question: I performed a fine needle aspiration biopsy on a breast mass (88170). Medicare denied payment because our records indicate that you billed diagnostic test(s) subject to price limitations; however, you did not indicate whether the tests were performed by an outside entity or if no purchased tests are included on the claim. (MA110 and CO-16 codes). How should I code this?

Connecticut Subscriber

Answer: In some instances, a provider will purchase part of a diagnostic test (the technical or professional component) from an independent entity, and pass these charges on when billing Medicare, says Eric Sandham, CPC, compliance educator with Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. Medicare has established limits to the amount that can be charged, and will not allow a purchasing provider to charge any markup. Box 20 of the Health Care Financing Administrations (HCFA) claim form is reserved to identify those diagnostic services that have been purchased from an independent laboratory or diagnostic facility, as well as the amount paid for them to indicate compliance with these guidelines.

The fine needle biopsy codes have a technical and professional component in the Medicare Fee Schedule database, evidently to indicate that the physician doesnt always provide the technical component (e.g., the cost of the needle and supplies for smear preparation). If you have performed the entire procedure and provided the supplies, bill the global procedure. If performing it in a hospital or facility where you are not responsible for the technical component, bill with the -26 modifier (professional component). In either case, check No in box 20 and you should receive payment.