Oncology & Hematology Coding Alert

Separately report appropriate imaging codes, such as 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]), Rasmussen says. Also note that you don't yet have ICD-9 codes to identify BIRADS III, IV and V that would make supporting the imaging easier, she adds. So expect some trouble with uninformed payers.

You should warn your physicians that carriers may start requiring that the operative notes document the BIRADS level and encourage them to start making that notation now, Rasmussen says. "Better to be forearmed and forewarned."

If the palpable lesion is difficult to biopsy using palpation and therefore covered by Medicare you must submit documentation in the note that shows that difficulty, Rasmussen says. Contractors will then use their discretion to decide whether the palpable lesions were, in fact, difficult to biopsy.

To get breast biopsy codes paid, you need to select the correct diagnosis from the pathology report. And you can't go into that half-heartedly.

"It's your responsibility as coders to pull the correct code from this information" in the pathology report, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. There are many types of benign and malignant neoplasms, and the pathology report will reflect that range. The report could say squamous cell carcinoma, breast tissue with fibrocystic changes, normal breast tissues with hyperplastic changes, or simple cyst. And it may describe that the cells have their origin somewhere else in the body, she warns.

If the type of neoplasm described in the report looks unfamiliar to you, look it up, Bucknam says. Don't assume the neoplasm is malignant, she adds. You can usually find its type in the ICD-9 manual's index. For example, the instruction under "carcinoma" is "see also Neoplasm by site, malignant," she says.

Select the correct code for the neoplasm from the table of neoplasms in your ICD-9 manual, she says. If you don't find the specific cells described in the pathology report in the ICD-9 book, you should look the terms up in a medical dictionary to define whether tumors are malignant or benign before you select a code.

Look out for other indicators in the pathology report, including those that report diagnoses that aren't neoplasms. If the pathology report shows that the patient has fibrocystic disease of the breast, you should know that this disease is not a neoplasm, Bucknam says. Report 610.1 (Diffuse cystic mastopathy) instead.

If the pathology report indicates hyperplastic changes or hyperplasia, you should base your code selection on other contextual evidence. This neoplasm category doesn't indicate to the payer uncertainty about the diagnosis but rather uncertainty about its malignancy, Bucknam says.

When the pathology report also mentions cells from another part of the body, you have a metastatic neoplasm. You could even see that term in the report, Bucknam says. In either case, select your diagnosis code from the second neoplasm category, but be careful not to assume that just because the patient has metastatic cancer in another part of her body means she has metastatic breast cancer, she says.

If, for some reason, you absolutely can't get the pathology report, you should code the neoplasm as unspecified. Make sure the pathologist is not sending you the report. Sometimes the report may be arriving to your surgical coding department later than you would like, but you should wait before charging the services, Bucknam adds.

Sometimes radiological and surgical oncologist coders butt heads when reporting breast biopsies done with radiological or imaging guidance. The radiological codes you should report with breast biopsy are:

If the oncologist performs a biopsy in a facility outside of his or her practice, such as a local hospital, you should append modifier -26 (Professional component) to the radiology services, and the hospital will bill for the technical component, Bucknam says.

If the radiologist is in the room with the oncologist but doesn't perform the biopsy, you should discuss with your physician or radiologist the coordination-of-care issues. The radiologist can bill for the supervision and interpretation, and if both the radiologist and the oncology physician submit bills for the same services, the insurance company will pay the one that's received first, Bucknam says.

Both sets of coders should encourage their specialists to discuss payment coordination to prevent what ends up igniting "a great deal of hard feelings," Bucknam says. Usually when both the radiologist and the oncologist are present, payment decisions and compromises are made based on who owns the equipment and the space, and other considerations, she adds.