General Surgery Coding Alert

Question: Our surgeon performed a percutaneous breast biopsy, placing a marker and using stereotactic guidance for a lump in the patient’s left breast. During the same operative session, the surgeon performed a percutaneous needle core biopsy of a more superficial lump in the patient’s right breast. Can we separately report two biopsies for full pay, and if so, what code(s) and/or modifiers do we need for these multiple procedures?

Texas Subscriber

Answer: Yes, you can separately report two procedures, and the correct codes are 19081 (Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance) for the left breast procedure, and 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)) for the right breast biopsy. 

Although the National Correct Coding Initiative (NCCI) bundles these codes, with 19100 a column 2 code with 19081, you can override the edit pair because you’re reporting the two codes for different anatomic sites.

Do this: Report 19100 with modifier 59 (Distinct procedural service) or an appropriate X(EPSU) modifier such as XS (Separate structure…).

Avoid: Although these represent “multiple procedures,” you shouldn’t use modifier 51 (Multiple procedures). Most payers ignore this modifier, which will not override an NCCI edit, and Medicare payers may even deny a claim with this modifier.

Payment: Even though you shouldn’t use modifier 51, you should expect your payer to reduce the fees because your surgeon performs multiple procedures in a single operative session. Payers typically pay the first procedure at 100 percent of the allowable, and the second procedure at 50 percent of the allowable. You shouldn’t reduce the charge on your claim — the payer will make the reduction during processing.