Oncology & Hematology Coding Alert

Remember, not all biopsies are the same.

Suppose a biopsy claim lands on your desk. Do you know how to code this? Two key elements are highlighting how your oncologist performed the procedure and whether it included imaging guidance.

Before that claim lands in limbo land because of incorrect reporting, refresh your knowledge of the relevant codes and how you use them with these three hints.

Hint 1: Know How the Procedures Differ

First, a little clinical background. Fine needle aspirations (FNAs) use needles that are much thinner than those used in percutaneous needle biopsy (PNB) procedures. That makes FNAs ideal for removing fluid and small pieces of tissue (called aspirate) from the skin and other areas of the body close to the surface, or from regions such as the testis or epididymis. But the technique may not remove enough material for the biopsy to enable a definitive cancer diagnosis.

That’s where PNBs come in. They use a larger needle to remove a bigger tissue sample, a procedure that is more complex than an FNA and can involve the use of a local anesthetic to numb the area of the body from which the sample will be taken (Source: www.cancer.org/treatment/ understanding-your-diagnosis/tests/testing-biopsy-and-cytology-specimens-for-cancer/biopsy-types.html). Providers commonly use this technique on larger bodily structures, such as the breast or the prostate.

Coding alert: As PNBs involve more work, payers commonly reimburse them at a higher level than FNAs. Currently, the Medicare national average nonfacility fee for 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion) is $105.38, while Medicare reimburses a PNB procedure, such as 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) at $256.46.

This means you must query your providers if you do not know which method they used to perform a biopsy.

Hint 2: Know How CPT^® Classifies the Procedures

FNAs are relatively easy to find in the CPT^® manual as they are all grouped together in the surgery section. Each of the five parent codes describes aspiration of a single lesion either without or with guidance; a further five add-on codes allow you to report additional lesions aspirated. So, if your provider aspirates three lesions using ultrasound guidance, you’ll report one unit of 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion) and two units of +10006 (… each additional lesion (List separately in addition to code for primary procedure)).

PNBs are a little trickier to find as most are anatomically specific. This means you’ll have to use the index, where you will find the majority of them listed by anatomic site under the entry for Needle Biopsy. There, the index will direct you to such codes as 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)) for a breast biopsy, and 55700 or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) for prostate biopsies conducted using different approaches.

You’ll also find some of these PNB procedures in the index under the entry for Biopsy, while you can locate FNA codes under Fine Needle Aspiration Biopsy or under the entry for Lesion, Skin.

Hint 3: Know How to Code Multiple Biopsies

You should only use the coding in the multiple FNA example above when multiple biopsies are “performed on separate lesions at the same session, same day, [and the] same imaging modality,” according to CPT^®. You’ll simply use the appropriate primary code for the first aspiration and “the appropriate imaging modality add-on code for the second and subsequent lesion(s),” CPT^® continues.

But what happens when your provider uses different imaging modalities for aspirations performed on the same day at the same session? In such instances, CPT^® instructs you to use modifier 59 (Distinct procedural service) “for each additional imaging modality and corresponding add-on codes for subsequent lesions sampled,” after reporting the primary FNA code.

You’ll do something similar if your provider performs a FNA and a PNB biopsy on different lesions during the same session on the same day, but only if your provider uses the same imaging guidance for both procedures. In that case, you’ll report the core needle biopsy and the imaging guidance separately with modifier 59.

Keep in mind: “The Centers for Medicare and Medicaid Services [CMS] introduced the X modifiers [XU, XS, XP, XE] as a subset of modifier 59, and your payer may want to see one of those modifiers instead,” says Kelly Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC in Charlotte, North Carolina. So, you may need to append one of the following as applicable:

• XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)
• XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)
• XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner)
• XE (Separate encounter, a service that is distinct because it occurred during a separate encounter).

But if the provider performs the FNA biopsy and core needle biopsy on the same lesion, in the same session and on the same day using the same type of imaging guidance, you won’t be able to separately report the imaging guidance for the core needle biopsy.