General Surgery Coding Alert

Question: If the surgeon performs both a fine needle aspiration and a core needle biopsy for a breast mass, can we code both procedures? Answer: For Medicare, and potentially other payers as well, you should not report a fine needle aspiration (FNA) and core needle biopsy from the same breast mass. Medicare's Correct Coding Initiative (CCI) restricts when you can get paid for the following codes FNA codes: 10021 -- Fine needle aspiration; without imaging guidance 10022 -- ... with imaging guidance. These two FNA codes are column 2 (component) codes for the following core needle biopsy codes: 19100 -- Biopsy of breast; percutaneous needle core, not using imaging guidance (separate procedure) 19101 -- ... open incisional 19102 -- ... percutaneous, needle core, using imaging guidance 19103 -- ... percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance. If the surgeon provides documentation that the FNA and core needle biopsy are for separate sites [...]