Oncology & Hematology Coding Alert

Two of the more significant changes in CPT 2002 are the new codes for bone marrow biopsies and aspirations:
  

38220 bone marrow aspiration 

38221 bone marrow biopsy, needle or trocar.

These codes replace bone marrow biopsy code 85102 and bone marrow aspiration code 85095.
 
The change moves the bone marrow procedures out of the pathology and laboratory section of the CPT and into the surgery section of the manual. This revision identifies the removal of bone marrow as a surgical procedure, rather than a surgical pathology procedure.
 
However, the change in procedure codes is unlikely to affect Medicare's position for not reimbursing bone marrow biopsies and aspirations separately, according to the American Society of Clinical Oncology's department of public policy and practice.
 
From Medicare's perspective, the biopsy and aspiration are the same because the two samples marrow and bone are drawn from one incision, removed from the same site, and often with the same needle. In its Correct Coding Initiative (CCI), CMS directs carriers to pay for the biopsy but not the aspiration if reported together. Therefore, oncology practices can bill 38220 or 38221.

Prove Distinct Services

Oncologists have argued unsuccessfully that biopsies and aspirations, while closely related, are separate procedures.
 
CCI provides an exemption when one of the codes is accompanied by modifier -59 (distinct procedural service). Practices should report bone marrow biopsies and bone marrow aspirations separately and append modifier -59 to either one, says Nancy Giacomozzi, manager at P.K. Administrative Services in Englewood, Colo.
 
To apply modifier -59 appropriately, the oncology practice must be able to prove that 38220 and 38221 are independent of each other.
 
If the biopsy and aspiration were taken from separate sites from each side of the hip, for example that is considered two separate procedures. However, this rarely occurs. 
 
Some oncologists perform an aspiration by inserting a fine needle into the hip or sternum where bone marrow is pulled up into a syringe. A biopsy is done by inserting a larger needle into the same area. The needle is pushed down until a small piece of bone is obtained. The use of two needles can be interpreted as distinct procedures, says Stephanie Thompson, CPC, practice manager for Lexington Oncology Associates, an oncology practice in Lexington, Ky. 
 
Along with appending modifier -59 to 38220 or 38221, the physician should document the gauge of both needles to make it clear that two were used as well as a description of the techniques followed to aspirate and biopsy the bone marrow.
 
Unfortunately, if the oncologist uses only one needle, the oncology practice would have no choice but to bill 38220 or 38221.

If the oncologist or hematologist performs an interpretation service, he or she may bill for the professional component associated with examining the marrow and bone samples. The technical component is considered to be the performance of the test and is generally performed by nonphysician personnel and/or automated equipment. 
 
For example, physician hematology services include microscopic evaluation of bone marrow aspiration and biopsies. Hematology services also include a limited number of peripheral blood smears that need to be referred to a physician to evaluate the nature of an apparent abnormality identified by the technologist.
 
The physician can bill for the professional component of two lab procedures: 

85097 bone marrow, smear interpretation,

88305 level IV - surgical pathology, gross and microscopic examination.

Modifier -26 (professional component) should be appended to the above codes to report physician involvement in the interpretation of the procedures.

To get paid for bone marrow aspiration and bone marrow biopsy, some practices report 20220 (biopsy, bone, trocar, or needle; superficial [e.g., ilium, sternum, spinous process, ribs]) with 85095 (38220 in CPT 2002).
 
While 20220 will pass through CCI edits, it is the wrong code to report, Thompson says. Code 20220 is reserved for bone biopsies, not bone marrow biopsies. Some physicians may argue that bone marrow is part of the bone. Code 38220 differs from 20220 because 20220 requires the physician to obtain a sample of compact or hard bone from the bone cortex. The determining factor,  Thompson says, is where the abnormality is suspected. The answer is either bone marrow or the bone. The two are not interchangeable.