Oncology & Hematology Coding Alert

If your physician's work doesn't meet unbundling criteria, however, you should not report these codes separately, Neltner says. Instead report the biopsy code, 38221, alone it covers both procedures. The following three examples show you when you can and can't unbundle biopsies and aspirations with modifier -59.

Example #1: A patient presents to the clinic, and your physician performs a bone marrow aspiration and biopsy of the right iliac crest. These procedures occur in the same site, in the same bone, during the same patient encounter. You cannot unbundle these procedures. You should report only 38221, Davis says.

Example #2: The physician performs the same procedures in Example #1 but also does a bone marrow aspiration on the sternum's left side. As stated in the previous example, you cannot unbundle the procedures on the right side.

You can, however, report the aspiration on the left side separately from the biopsy on the right because you have two different anatomic sites. You should report the following codes: 38220 with modifier -59 for the left side and 38221 for the right side, Davis says. Code 38221 is your primary procedure code for that particular date of service, she adds.

Example #3: The physician performs a bone marrow aspiration and prepares and interprets a slide to see whether to take the aspiration from another site, 85097 (Bone marrow, smear interpretation). The physician then returns to the original site and performs a biopsy later that day.

In this case, you cannot report this biopsy in addition to the aspiration with modifier -59, Davis says. Although these procedures technically occur during separate encounters, they're effectively bundled your physician performed the aspiration to do the biopsy procedure. They are not distinct procedures.

In other cases, you can unbundle 38220 and 38221 for different patient encounters if the physician performed these two procedures as separate procedures. You need to demonstrate that the aspiration is not a procedure preliminary to a biopsy on the same site.

If you don't have the documentation to support unbundling, correct modifiers won't do you any good.

Documentation showing two distinct procedures is what you need to justify your unbundling to payers, Neltner says.

Teach your physicians to precisely dictate their procedures, following the actual operative guidelines for notes, Davis says. If need be, ask your physicians for addendums to their dictation that justify the work they did, she says.

Without proof of two separate incisions, sites or encounters, you will have a hard time proving two distinct procedures, she warns.

Let your physicians know how important their documentation is to payment for more than one code, Davis says. Print out Medicare guidelines and other useful sources, including NCCI edit information, and offer it to your physicians as incentive to beef up documentation, she states.

In addition, make medical records readily available to hand over to Medicare. Your carrier will likely ask for them, no matter how sufficient your documentation, to verify that you've unbundled the codes for appropriate reasons, Davis says.

Do not use modifier -51 (Multiple procedures) when you report a bone marrow aspiration and biopsy, Davis says. According to NCCI guidelines, you cannot use modifier -51 to report any bundled codes separately even though NCCI permits you to unbundle under certain circumstances, she says.

So if you report both 38220 and 38221 with modifier -51, expect denials, even from Medicare, Davis warns.

CMS payment policies published Dec. 31, 2002, in the Federal Register have confused many coders on this issue don't let them confuse you. In Volume #67, number 251, page 79992, the FR lists a comment addressing modifier -51 and these procedures, but it doesn't respond on the appropriateness of using modifier -51. You should therefore default to the NCCI edits and modifier -59, which CMS explicitly allows in that section.

Even if you stick to unbundling guidelines, you could see denials for reporting bone marrow biopsies and aspirations separately.

To increase your payment chances, verify that these services meet not only their standard unbundling requirements but also additional, more specified circumstances.

You can find these additional circumstances in the checklist below, offered by Neltner. This guidance, not yet national Medicare policy, comes directly from a meeting with CMS representatives. The meeting's testimony comes from Cary A. Presant, MD, FACP, professor of clinical medicine at the University of Southern California School of Medicine, president of the Medical Oncology Association of Southern California, and president of California Medical Center.

Report bone marrow biopsies and aspirations separately if all of the standard requirements and these additional, more specific circumstances apply: