Oncology & Hematology Coding Alert

Ambiguous statements by Medicare in the 2003 Physician Fee Schedule regarding the use of modifiers with bone marrow biopsy and aspiration procedures mean that oncology coders are still singing the bundling blues.

Now, physician work RVUs for 38220 (Bone marrow; aspiration only) are 1.08 with a nonfacility practice expense rate of 4.64, and 0.43 in the facility. For 38221 (... biopsy, needle or trocar), they are 1.37 with a nonfacility practice rate expense of 4.79, and 0.54 in the facility.

The new year leaves the two codes effectively bundled. "If you do a biopsy, then you also did an aspiration, because that's the only way you're going to get the sample for the biopsy," says Carolyn M. Davis, CMA, CPC, CCP, CCS-P, CPHT, TMC, the billing supervisor for Oncology Hematology West in Papillion, Neb., and a professional coding and continuing education instructor (through AAPC) at Iowa Western Community College.

Davis says that the only way you can get them paid separately is if you can show that the procedure involved separate or bilateral sites.

Modifier -51 Is Like Area 51 Hard to Locate

In the 2003 Fee Schedule , CMS (agreeing with AMA) says that when a bone marrow biopsy and aspiration are performed through the same incision, you should report both 38220 and 38221 with modifier -51 (Multiple procedures) appended. (Editor's note: See 67 Fed. Reg. 79992.)

But CMS'buy-in to the modifier -51 strategy defies the logic of CPT 2003, Davis thinks. "Because the definition of 38221 in the 2003 CPT code book now includes aspiration and biopsy, it's going to be hard to use the -51 modifier," she says.

This scenario could occur if a pathologist does the actual procedure, Davis suggests. After performing an initial aspiration and running a slide mid-procedure, the physician might go to a different area in the same site and pull a biopsy of the bone marrow and run that study. You can then use modifier -51 with 38220 and 38221, Davis says, because you can prove that the pathologist did two different procedures through the same incision.

But, Davis cautions, this is an unusual example, and you'd want to use extreme care with your documentation. The 38220 would refer strictly to the aspiration that the physician looked at, while 38221 would refer to the biopsy taken in the secondary procedure. Actual payment will probably depend on local Medicare carrier policy, she says.

Last Word on Modifiers -50 and -59

CMS'guidance in the fee schedule doesn't supercede the use of modifier -50 (Bilateral procedure) for a standard bilateral bone marrow biopsy, says Jeanne Potter, CCS-P, CPC, the state reimbursement specialist with US Oncology in Schaumburg, Ill.

If an identical procedure is done bilaterally, such as two aspirations or two bone marrow biopsies in the right and left hip respectively, then -50 would be the correct modifier, agrees Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans.

However, Hickey says, "if the physician doesn't do exactly the same procedure on both sides, then you would want to use the -59 modifier (Distinct procedural service). For example, "If the oncologist does an aspiration on the right hip and a bone marrow aspiration plus a biopsy in the left hip, then you can't bill for bilateral aspirations because the biopsy-aspiration is bundled on the left side, while the aspiration would be a separate code on the right side."

Referencing guidance published on June 28, 2002, in the Federal Register, Potter agrees that "in order to bill for both procedures, they have to be performed in separate sites." She has found that many practices are making the mistake of billing both procedures, even when they are performed in the same site.

Additionally, oncologists may perform bone marrow biopsies from the sternum, which isn't a bilateral site, Hickey adds. "If the doctor biopsied a hip and a sternum, that's two separate sites, yet it wouldn't make sense to call them bilateral."

CMS also advises that if the aspiration and biopsy are performed at different, nonbilateral sites, aspiration and biopsy codes would each be used along with modifier -59.

Current coding conventions dictate that "you still want to retain the option of using the -59 modifier," Hickey reiterates. "This is by far the most common modifier with bone marrow biopsies and aspirations. However, you should always use the more distinct code."

Separate Codes for Pathologist and Hematologist

Davis explains that 88305 (Surgical pathology, gross and microscopic examination, bone marrow, biopsy) is the process of running a full spectrum of tests on the bone marrow in order to obtain an actual diagnosis.

Regarding this code, Potter clarifies a common question: "Only the pathologist who accesses, examines and reports the gross and microscopic biopsy can bill 88305. No other provider should use this code."

In contrast, the simpler smear viewed under a microscope is coded with 85097 (Bone marrow, smear interpretation). When billing for the hematologist or oncologist who is interpreting the smear, you should use 85097, Hickey says.

These two codes rarely show up on the same claim. But Davis offers one example in which they might: "If you have a pathologist doing the bone marrow procedure, he will sometimes do a smear interpretation on that aspiration to see if further study is required. If the pathologist goes on to do the biopsy as well, he could conceivably use both codes."

In this special case, Davis, says, the codes should be billed with modifier -59 "because they're going to have to indicate that the interpretation is separate from 88305."

After you master the bundling brouhaha, the final challenge with bone marrow biopsies is making sure that the physician has all the required documentation.