General Surgery Coding Alert

Question: Our surgeon performed an FNA of the right thyroid, and FNA of a nodule of the right thyroid isthmus. Both specimens were inadequate for diagnosis, according to the pathologist’s intra-operative exam. The surgeon then proceeded to perform a right thyroid core biopsy and a core biopsy of the right isthmic nodule. Should we report two units of FNA and core biopsy, as well as four units of radiology for the ultrasound guidance?

Missouri Subscriber

Answer: Payer rules vary, but generally speaking the FNAx2 (10022, Fine needle aspiration; with imaging guidance) and core biopsyx2 (60100, Biopsy thyroid, percutaneous core needle) should be acceptable to most payers for the circumstances you describe.

How many units you can report for ultrasound guidance (76942, Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation)will depend on payer policy. Medicare has in place a medically unlikely edit (MUE) unit of 1 for 76942.

FNA and biopsy together: You’re allowed to report both the FNA and core biopsies to Medicare in this case because documentation states that the FNA samples were inadequate. Append modifier 59 (Distinct procedural service) to 10022 to override the Correct Coding Initiative (CCI) edit pair for 10022 and 60100.

The CCI manual states,“Fine needle aspiration (FNA) (CPT^® codes 10021, 10022) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the other biopsy procedure code may also be reported with an NCCI-associated modifier,” (Chapter 3, Section L.11 in the current manual).

You should check individual payer policies, however. Some payers may have a policy that you should report only the final procedure that results in a diagnostically viable specimen.

Check units: Section K.3 of the manual states, “The unit of service for fine needle aspiration (CPT^® codes 10021 and 10022) is the separately identifiable lesion. If a physician performs multiple “passes” into the same lesion to obtain multiple specimens, only one unit of service may be reported. However, a separate unit of service may be reported for separate aspiration(s) of a distinct separately identifiable lesion.”

Each separate lesion should be reportable for core biopsy (60100) as well, although, again, payers may vary. For example, some payers require documentation to support reporting more than one biopsy.

US:For the ultrasound guidance, the CCI manual, Section G.3 of chapter IX states, “CPT^® codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.”

On the other hand:CPT Assistant^® April 2005 states, “From a CPT^® coding perspective, code 76942 should be reported per distinct lesion that requires separate needle placement.” So again, see what your payer allows.