Oncology & Hematology Coding Alert

Here’s what to do if your MD changes their imaging guidance method.

Even in this era of social distancing and telehealth, your oncologist may be required to see a patient to perform a fine needle aspiration (FNA) of the thyroid — which means you need to know how to code this service. For FNA claims, you have two prime challenges: 1) whether to report a biopsy with FNA, and 2) how many units you should report. Here’s how to conquer these issues.

Example: You may read your physician performed FNA of the right thyroid and FNA of a nodule of the right thyroid isthmus with ultrasound guidance.

Next, you’ll need to check the documentation to determine whether the procedure used imaging guidance.

If not, you’ll report 10021 (Fine needle aspiration biopsy, without imaging guidance…) and if a second lesion was done, you’d add +10004 (Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)).

If the oncologist performed an FNA biopsy with imaging guidance, use one of the following codes based upon the type used:

• 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)
• +10006 (… each additional lesion (List separately in addition to code for primary procedure))
• 10007 (Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion)
• +10008 (… each additional lesion (List separately in addition to code for primary procedure))
• 10009 (Fine needle aspiration biopsy, including CT guidance; first lesion)
• +10010 (… each additional lesion (List separately in addition to code for primary procedure))
• 10011 (Fine needle aspiration biopsy, including MR guidance; first lesion)
• +10012 (… each additional lesion (List separately in addition to code for primary procedure)).

Since in the example above, the oncologist used ultrasound imaging for the FNAs. You would report 10005, +10006.

Check Units for Fine Needle Aspiration

When reporting FNA, keep a count on lesions to be able to report the correct units. Chapter 3, Section K.3, of the National Correct Coding Initiative (NCCI) manual states, “The unit of service for fine needle aspiration biopsy, CPT^® codes (CPT^® codes +10004-+10012 and 10021) is the separately identifiable lesion. If a physician performs multiple ‘passes’ into the same lesion to obtain multiple specimens, only one unit of service may be reported. However, a separate unit of service may be reported for a separate aspiration biopsy of a distinct separately identifiable lesion.”

In other words, you should tally how many lesions are being aspirated. For instance, if no imaging guidance was utilized, you can report 10021 and +10004 x 2 if the oncologist performs and documentation supports the aspiration on three separate lesions. The same logic applies for codes 10005-+10012 if imaging guidance was used and documented.

In the example above, you would report 10005, and add on code +10006.

What if: Suppose, in the above example, you also read that the pathology examination stated that ‘Both specimens were inadequate for diagnosis.’ Then following this, you see your physician performed and documents the immediate performance of a right thyroid core biopsy and a core biopsy of the right isthmic nodule at the same encounter as the FNA.

According to The NCCI manual, “12. Fine needle aspiration (FNA) biopsies (CPT^® codes +10004-+10012, and 10021) shall not be reported with a biopsy procedure code for the same lesion. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the physician shall report only one code, either the biopsy code or the FNA code. (CPT^® code 10022 was deleted January 1, 2019.),” (Chapter 3, Section L.12, in the current manual, available at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html).

Therefore, for Medicare, you would instead report 60100 (Biopsy thyroid, percutaneous core needle) x 2, one from which each lesion the core needle biopsy was obtained. In this case the physician obtained a core needle biopsy from the right thyroid and the right isthmic nodule.

Payer alert: You should also check individual payer policies. Those who do not use the CCI edits and guidance may allow both procedures needed to obtain a diagnostically viable specimen.