Internal Medicine Coding Alert
'Fat Pad Biopsy' Code Depends on Method
Question: Our internist wrote in the documentation that he performed a "fat pad biopsy." I am unsure of what the procedure is and which code to use. I have considered assigning an unlisted-procedure code. Do you have any advice? Answer: The proper code depends on the method the doctor used to perform the biopsy. Often internal medicine coders submit 10021 (Fine needle aspiration; without imaging guidance) because a fat bad biopsy involves removing a small portion of the patient's abdominal wall or "fat pad."
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Typically, an internist uses this procedure to test for amyloidosis (277.3), which ICD-9 defines as "Conditions of diverse etiologies characterized by the accumulation of insoluble fibrillar proteins (amyloid) in various organs and tissues of the body, compromising vital functions."
Often needle aspiration (10021) is the most effective procedure for removing the fat pad. Before reporting 10021, make sure to confirm the code with the physician and the physician's documentation to ensure that the physician used this procedure to obtain the biopsy.
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