General Surgery Coding Alert

Question: The surgeon performs two breast needle core biopsies under fluoroscopic guidance in the hospital setting, one from the left and one from the right breast. The procedure includes placing a localization clip in each breast to mark lesion location. The surgeon closes the two surgical fields and sends the samples to pathology. How should we code the procedure?

Louisiana Subscriber

Answer: You should report the primary procedure as 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance). Append modifier 50 (Bilateral procedure) since your surgeon performed a biopsy on each breast.

Additionally, you can report 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) for the fluoroscopic guidance if your surgeon performs the work. If the surgeon only supervises and interprets the fluoroscopy results in the hospital setting, you should report 77002 with modifier 26 (Professional component).

Capture clip: For the clip placement, you can bill +19295 x 2 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration [List separately in addition to code for primary procedure]).

Caution: If a radiologist other than the surgeon performing the needle core biopsy provides imaging guidance during the procedure, that radiologist -- not the surgeon -- should report the radiologic supervision and interpretation code.