General Surgery Coding Alert

Question: How can I distinguish fine needle aspiration from puncture aspiration? What makes these procedures distinct?


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Answer: During fine needle aspiration (FNA), the physician uses a fine-gauge needle (from 18 to 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. The surgeon may make several passes to obtain an adequate tissue specimen. You can report these procedures using 10021 (Fine needle aspiration; without imaging guidance) and 10022 (... with imaging guidance).

When the surgeon performs a puncture aspiration to identify or drain a breast cyst, he inserts a needle into the cyst and withdraws the fluid contained in the cyst. He may  send the fluid to the lab for biopsy, depending on the cyst's nature. The procedure's primary purpose, however, is to aspirate the cyst, not to biopsy the contents.

If your doctor performs a puncture aspiration, you should report 19000 (Puncture aspiration of cyst of breast) and +19001 (... each additional cyst [list separately in addition to code for primary procedure]). Use 19001 when the surgeon performs more than one puncture aspiration on the same breast, and always use 19001 in addition to 19000.

If the physician aspirates a cyst from each breast, you should report 19000-50 (Bilateral procedure).

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P.