Ob-Gyn Coding Alert

Break Out of Breast Biopsy Denials With This Foolproof Modifier Advice

Published on Thu Apr 28, 2005

If there's more than 1 biopsy, look to -50, -51 and -59

If you're constantly battling payers over the reduction of reimbursements and denials of second procedures along with breast lesion excisions or breast biopsies, this expert coding advice is for you.

In most cases, if an ob-gyn performs a breast biopsy, he will only extract a small portion of the lesion. For this reason, you're not likely to report additional codes for wound closure or skin grafts, but you might report more than one biopsy per breast or multiple biopsies in both breasts, says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert in Fredericksburg, Va.

You may also find that you report adjunct procedures such as 1) placement of a clip to identify the site if the biopsy should come back as malignant or 2) radiologic imaging procedures.

What to Expect: You'll receive full reimbursement for the first biopsy, but payers will discount the amounts for any additional surgical procedures. Payers reimburse only for the intraoperative portion for additional biopsies and procedures. You can expect full payment for at least the professional component for a radiologic imaging procedure. Also, if the payer uses Medicare guidelines, you won't be reimbursed separately for any anesthesia service including conscious sedation - that includes supplies as well.

Ask 2 Questions for Needle Biopsies

When an ob-gyn performs a biopsy through the skin using a needle, scalpel or rotating biopsy device, you'll have six code choices to choose from:

10021 - Fine needle aspiration; without imaging guidance

10022 - ... with imaging guidance

19100 - Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)

19101 - ... open incisional

19102 - ... percutaneous, needle core, using imaging guidance

19103 - ... percutaneous, automated vacuum-assisted or rotating biopsy device, using imaging guidance.

If the ob-gyn performs the biopsy using a needle, you should ask yourself two questions: First, did he incise the skin prior to inserting the needle into the lesion? Second, was the specimen collected using imaging guidance? The answers will help you pick appropriately between a fine needle and needle core biopsy. An open incisional biopsy would not involve use of a needle to collect the specimen.

Know your terms: "Percutaneous" means that a small skin incision has been made to ease the insertion of the needle into the lesion; using sutures to close the incision would be included as part of the procedure, Witt says.

Note: If the ob-gyn performs the biopsy using an automated vacuum or rotating biopsy device, then there should always be imaging documentation.

How to Report More Than 1 Biopsy

If the ob-gyn performs more than one biopsy, you would reflect this by using modifier -50 (Bilateral procedure), modifier -51 (Multiple procedures), or modifier -59 (Distinct procedural service).

The challenge is that you won't find a standard protocol for submitting claims for bilateral procedures, says Sangeeta Parekh, CPC, practice plan administrator for the USC Department of Surgery, Division of Tumor and Endocrine Surgery, in Los Angeles.

Example 1: The ob-gyn performs a single percutaneous biopsy with imaging guidance on a lesion of both the right and left breast. You should report 19102-50 (the CPT standard) with one of the following:

76095-26 - Stereotactic localization

76096-26 - Mammographic guidance for needle placement

76360-26 - CT guidance for needle placement

76393-26 - MR guidance for needle placement

76942-26 - U/S guidance for needle placement (if the ob-gyn performs one of these).

You don't need a multiple-procedure modifier for the radiologic code, but you will need to append modifier -26 (Professional component) unless your practice used its own equipment.

Example 2: The physician also placed a metallic localization clip into each lesion at the time of the biopsy. You should change the coding in the previous example to 19102-50, +19295 (Image guided placement, metallic localization clip, percutaneous, during breast biopsy [list separately in addition to code for primary procedure]) and 19295 again, plus any billable radiologic procedure.

Notice how you don't need modifier -51 on 19295. The reason is that 19295 is a CPT "add-on" code that never takes a modifier. You should report it for each clip the ob-gyn places.

Don't Miss Out on Modifier -59

You can report modifier -59, but you should only do so when the payer bundles the additional procedures.

Example: Your payer may bundle preoperative placement of a needle localization wire (19290) into the code for a fine needle aspiration with imaging (10022). If the ob-gyn can make a case that he placed the wire on the same service date but at a different session, you can report the two procedures as 19290-59 and 10022-51. Keep in mind that the RVUs for the needle placement are higher than the RVUs for the fine needle aspiration, hence the placement code, which is normally bundled, goes first.