General Surgery Coding Alert

AAPC Forum Participant

Answer: It’s not uncommon for a report on a US-guided FNA biopsy to use this type of language, suggesting that the surgeon carried out the same procedure on the opposite side. While the documentation you’ve mentioned isn’t perfect, it shouldn’t require an additional note for you to code the procedure as bilateral. You might consider advising your provider that, for optimal dictation practices, especially for protection against malpractice claims, it’s crucial to include specific details for each side.

As for the procedure coding, remember that 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)

has a medically unlikely edit (MUE) of 1. This means that you may report only one unit of 10005 on any given date of service (DOS). Reporting 10005 separately with modifiers LT (Left side) and RT (Right side) is inappropriate, and the payer will deny the service.

Consider the following CPT^® Assistant guidelines:

• “Codes 10004-10012 and 10021 may be reported only once per lesion sampled in a single session. When more than one FNA biopsy is performed on separate lesions at the same session, on the same day, and using the same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s).”

Based on these instructions, you should report 10005 with modifier RT for the first lesion of the right breast and 10006 (… each additional lesion (List separately in addition to code for primary procedure)) with modifier LT for the second lesion of the left breast.