Ob-Gyn Coding Alert

Although CPT 2002 introduced specific new codes for fine needle aspiration (FNA), those codes didn't clear up much of the confusion about how they apply.
 
When a physician performs an aspiration of a breast cyst but does not perform pathology, questions remain about how the service should be charged and whether to use new or existing codes for the procedure(s).
 
FNA is most often used in the ob/gyn setting to obtain a breast tissue sample for biopsy, or to aspirate a breast cyst. "There still seems to be a lot of uncertainty when it comes to breast aspiration and biopsies," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., "largely because of the different equipment used."
 
Callaway offers ways to tell the difference between FNA, other aspirations and biopsies:

 1. FNA involves a thin needle extracting a small sample of cells; a cyst aspiration uses a larger needle that extracts all of the contents of a cyst; a biopsy takes a core specimen or a larger piece of the breast mass.

 2. FNA is used as an initial analysis of cyst content; cyst aspiration is used when the cyst becomes painful or large enough to be uncomfortable to the patient; a biopsy is performed when the physician feels there is a very real threat of malignancy.

This method of destroying a breast cyst involves inserting a needle into the cyst and withdrawing the fluid contained in the cyst. The fluid may be sent to the lab for biopsy, depending on the nature of the cyst or cysts. The patient's history will usually determine the physician's decision to have the cyst fluid sent for biopsy. The primary purpose of this procedure, however, is to treat the cyst and not to biopsy the contents.
 
The codes for puncture aspiration are 19000 (Puncture aspiration of cyst of breast) and 19001 ( each additional cyst [list separately in addition to code for primary procedure]).
 
Use 19001 when more than one puncture aspiration is performed on the same breast and always in addition to 19000. Use 19000-50 (Bilateral procedure), rather than 19001, when cysts are aspirated from both breasts.

FNA is used to obtain cells from a solid tumor of the breast, though it may be used for other organs as well. A thin needle is inserted into the breast mass so the syringe can vacuum up cells from the mass.
 
FNA codes listed in the Cytopathology section of the CPT manual were replaced in 2002 with two new codes that more clearly identify FNA as a surgical procedure. "The new codes were created," says Melanie Witt, RN, CPC, MA, an independent coding consultant and ob/gyn coding expert based in Fredericksburg, Va., "because very often the ob/gyn or other specialist may obtain the sample from the patient but may not always evaluate the sample, whereas the old codes were for both aspects."
 
The two new codes are 10021 (Fine needle aspiration; without imaging guidance) and 10022 ( with imaging guidance).
     
If the ob/gyn checks the sample under the microscope first to ensure an adequate sample, bill 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) in addition to the aspiration code. The cells are normally sent to the pathologist for evaluation, however, and the lab would normally report 88173 ( interpretation and report). CPT also notes that if the aspiration takes place under imaging guidance (10022), report one of the following procedures if the physician performs the supervision and interpretation required: 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]), 76360 (Computerized axial tomographic guidance for needle biopsy, radiological supervision and interpretation) or 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation).
 
If a radiologist or another physician provides imaging guidance during the FNA, that physician (not the ob/gyn) reports the radiologic supervision and guidance code.

For a more traditional breast biopsy, a tissue sample is taken from the suspect region of the breast. While a biopsy can still be obtained using a needle, the procedure differs from an FNA in that it takes a larger sample and is analyzed differently in the lab. A surgical biopsy of the breast is coded from the following group: 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]), 19101 ( open, incisional), 19102 ( percutaneous, needle core, using imaging guidance) and 19103 ( percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance).
 
Since 19102 and 19103 involve imaging guidance, the imaging guidance may be coded separately. For instance, if a stereotactic breast biopsy was performed, 76095 (Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation) would also be reported. However, when reporting a stereotactic biopsy on a Medicare patient, you should only report the surgical part of the procedure using 19101.
 
"Although these procedures are fairly different from one another, coders still need to have a clear understanding of exactly what service their physician performed," Witt says. That means if it is not spelled out on the operative report, check with the physician to be certain the claim submitted matches the work done.