Oncology & Hematology Coding Alert

Watch out, mistakes will cost $78 per procedure.

When the oncologist merely documents “biopsy” for procedures when a specimen is obtained using a needle, you may find yourself wondering whether you should report a fine needle aspiration (FNA) or a percutaneous needle biopsy (PNB).

Here are tips on how you can steer clear of coding errors between these two procedures.

Tip 1: Watch Your Language

Your physicians may use “biopsy” as a universal term to mean they took a specimen sample. Vague documentation habits can contribute to coding errors involving these procedures, says Kelly Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner at Pinnacle Enterprise Risk Consulting Services LLC located in Charlotte, North Carolina.

Better way: Encourage your physician to reserve “biopsy” for procedures to remove a small tissue specimen for diagnosis, whether open, laparoscopic, or percutaneous. If the physician has this habit, you’ll know you really should look for the appropriate PNB code if the op note shows a needle is involved.

If your physician removes cellular material (“aspirate”) instead of tissue in a biopsy, turn to the FNA codes.

Helpful hint:  Code for FNA when your physician does an aspiration of the testis or epididymis. Your physician may also use PNB for these organs. For the prostate, your physician may almost always do a transrectal or perineal PNB to obtain prostatic material for analysis.

However, if physicians continue to use contradictory language in their documentation, a few hints will help you tell the procedures apart.

Tip 2: Procedures Have Own Sections

FNA and PNB are so different, CPT^® actually places the procedures in separate sections.

FNA has its own codes and are found in the integumentary section.

CPT^® 2019 introduced big changes to the FNA code selection. The old FNA codes, 10021 and 10022, only differentiated between with or without imaging guidance and were reported once per lesion.

The codes were updated/expanded to include imaging guidance options, when utilized. Additionally, the codes are now split where the parent code captures the first lesion. Add on codes represent each additional lesion. CPT^® defines these codes as:

Remember:  Code 10021 was revised in 2019 to include “…first lesion” with new add on code +10004 to represent each additional lesion. Code 10022 was deleted with the addition of 10005-+10012 for greater specificity regarding imaging guidance utilized as well as options for first and each additional lesion, Loya points out.

How to find PNB codes: Look for the anatomic site-specific surgery code.

Example: Your surgeon takes a percutaneous needle biopsy of the prostate. The most specific code available is one for the “incision procedures of the prostate.” You report code 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) for the PNB of the prostate.

Speed tip: To quickly locate an exact PNB code, look up “needle biopsy” in CPT^®’s index. Find the anatomical location your physician biopsied, such as the “epididymis,” and, presto, you can look up the specific CPT^® code to ensure it matches the procedure performed and documented. For biopsy of the epididymis, you would use 54800 (Biopsy of epididymis, needle).

Note: Your physician does not have to indicate the word “percutaneous.” Stating a “needle biopsy” in the procedure description is sufficient.

Tip 3: Biopsy Involves Larger Needle, Tissue Specimen

Other hints in the operative note to help you distinguish an FNA from a PNB are needle size and the specimen type.

“A percutaneous needle is much larger than a fine needle,” Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Specimen: “A fine needle takes out an ‘aspirate,’ which is a sort of fluid sent to the pathologist for analysis,” Cobuzzi says. “A percutaneous needle is larger and takes out tissue in the mass’s core.”

Key terms: You should associate fluid or cell sampling with FNA and core or tissue sampling with PNB.

Mistakes could cost you: If you miscode a PNB as a FNA, you stand to lose significant pay. For instance, if you had reported the earlier prostate example, the national average physician fee schedule (facility) reimbursement for 10021 is $58.02 compared to 55700 allowing $135.87, resulting in a difference of $77.85 when performing these procedures in hospital. When performed in the office, 10021 = $100.19 and 55700 = 256.60, resulting in a difference of $156.41 for a physician office error in coding.

Note: All payment values are based on the unadjusted Medicare Physician Fee Schedule with a conversion factor of 36.0391.