Oncology & Hematology Coding Alert

Don’t assume that all sample specimen retrievals are the same.

CPT® provides specific codes to describe both fine needle aspiration (FNA) and percutaneous needle biopsy (PNB). Your challenge lies in picking the right code for the right procedure, but you’ll choose correctly every time if you know how to differentiate between the two.

Hot tip: When trying to report FNA or PNB, you should make sure you are not reporting specimen sampling with a surgery code. Aspiration Doesn’t Equal Biopsy

You know you’ll need different codes for FNA and PNB; unfortunately, your physician’s notes may make telling what procedure he performed difficult.

For instance, you may be wondering, “What is the difference between fine needle aspiration biopsy and percutaneous needle biopsy?” Physicians may use biopsy as a universal term to mean that they took a sample of a specimen. If your clinician is in this habit, you may miscode his procedures.

Better method: Encourage your physician to reserve “biopsy” for a biopsy procedure. That way, you will know that a chart or operative report that contains the term, “biopsy,” really means the oncologist performed a biopsy.

If your oncologist continues to use contradictory language, a few hints will help you tell the terms apart.

Procedures Have Own Sections

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

Where to look for FNA codes: FNA has its own codes, which are found in the integumentary section. CPT® defines these codes as:

• 10021 — Fine needle aspiration; without imaging guidance
• 10022 — ... with imaging guidance.

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

Example: An oncologist takes a percutaneous biopsy of the salivary gland. When you look in the digestive system under the subheading “salivary gland and ducts,” you find 42400 (Biopsy of salivary gland; needle).

Speed tip: To quickly locate an exact PNB code, look up “needle biopsy” in CPT®’s index. Find the anatomical location the surgeon biopsied, such as the “thyroid gland,” and, voila, you can look up the specific CPT® code to ensure it is a match to the procedure performed and documented. In this case, a FNA of the thyroid gland is 60100 (Biopsy thyroid; percutaneous core needle).

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

Biopsy Involves Larger Needle, Specimen

To determine whether you should be using an integumentary system code or an anatomic-specific code, look at two key differences between a FNA and PNB.

1. Consider the needle’s size. “A percutaneous needle is much larger than a fine needle,” reports Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.
2. Check the specimen’s type. “A fine needle takes out an ‘aspirate,’ which is a sort of fluid that the oncologist sends 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.

In FNA, the physician uses a fine gauge needle (22 or 25 gauge- the higher the gauge number, the thinner the needle opening) and a syringe to draw the sample fluid from a cyst or remove clusters of cells from a solid mass. The sampling may involve several needle insertions to obtain an adequate tissue specimen or remove the necessary amount of fluid as clinically indicated.

On the other hand, PNB involves a single insertion. The oncologist uses the tip of a needle to collect tissue. Specifically, to remove tissue from the thyroid for examination, the physician passes a large, hollow bore needle through the skin into the thyroid.

Guidance, Cytology Report Signal FNA

You can further solidify your biopsy versus aspiration code selection if you look at a related service.

Here’s how: Check whether the oncologist needed imaging guidance to locate the mass. If he did, he performed FNA.

In the absence of ultrasound guidance, you should not assume that the procedure is not a FNA, as a FNA can be performed with or without ultrasound guidance.

When the oncologist can feel the lump, he usually doesn’t require imaging guidance. You should code FNA without imaging guidance as 10021.

If the lump is nonpalpable, the oncologist will use image guidance to perform the FNA. In this case, report 10022 for the FNA with imaging guidance.

Don’t be fooled: You can use code 10022 even if your physician doesn’t actually perform the imaging guidance himself. The code simply indicates that the procedure required imaging guidance - the code does not include the imaging service. “When used and billed by the physician performing the procedure, it is coded in additional to the FNA with code from the CPT® radiology section,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc.

If your oncologist performs the FNA and imaging guidance himself, you should report both 10022 and the appropriate guidance code, as follows:

• fluoroscopy — 77002 (Fluroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device])
• CAT scan — 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation)
• MRI — 77021 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration,
• injection, or placement of localization device] radiological supervision and interpretation)
• ultrasound — 76942.

If the FNA with imaging guidance occurred in a facility, you should only report the professional interpretation of the appropriate radiology codes. So, for example, for an ultrasound guided FNA performed in a facility, the otolaryngologist would submit 10022 and 76942-26. The facility would submit 76942-TC for the service.

“When someone other than the surgeon performs guidance, the provider performing guidance bills the radiology code(s),” says Loya. “For example, the medical record may state the oncologist performed the FNA in a radiology unit so another provider could perform the imaging guidance. In this case, you'd report 10022. In a radiology unit, the radiologist will report the imaging guidance with the appropriate code, such as 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation).”

Clever idea: A check on the pathology report in the patient’s chart will also help you select the right code. A cytology report from the pathologist indicates the patient had an FNA. If you find a histology report, code a PNB. “However, while the pathology report may provide a clue to the type of procedure the surgeon performed, it is important to ask the physician to clarify when the record does not adequately describe the service and fully supported for reporting to third party payers,” says Loya. “If a late entry or addendum is needed, always follow internal policy for responses to queries and late entries into the medical record to ensure compliance.”