General Surgery Coding Alert

Question: If a surgeon performs a breast-cyst aspiration and submits the aspirate to pathology for evaluation, should we bill the service as 10021?

Texas Subscriber

Answer: No, 10021 (Fine needle aspiration; without imaging guidance) is not the best code to describe a breast-cyst aspiration procedure. Instead, you should report 19000 (Puncture aspiration of cyst of breast).

Although the procedures are similar — the surgeon inserts a needle and withdraws fluid — the purpose and details of the procedures differ. The intention of a 19000 service is a treatment for the cyst, to drain it. The surgeon may or may not submit the contents to pathology, in these cases, depending on clinical parameters.

Nuance: If the surgeon aspirates a cyst from each breast, you should report 19000-50 (Bilateral procedure). If the surgeon aspirates multiple cysts from the same breast, you should report 19000 and +19001 (… each additional cyst (List separately in addition to code for primary procedure)) for each additional cyst.