Oncology & Hematology Coding Alert

Question: The physician performed the following procedure: Office pelvic ultrasound revealed solid and cystic components. Verbal consent obtained prior to procedure. Vulva cleaned with Betadine and 3ml of 0.5 percent Xylocaine with epinephrine injected into left vulva and wheel formed. 18 gauge needle then introduced into cyst with scant material returned. Hemostatic at end of procedure. Specimen sent for cytology. How should I report this?

New York Subscriber

Answer: For the CPT® code, you should consider this to be 10021 (Fine needle aspiration; without imaging guidance). The physician appears to have performed the FNA of a cyst of the vulva without image guidance. Image guidance would mean the use of ultrasound to help visualize the procedure, not a diagnostic ultrasound before the procedure, as described in this case. If the physician did use imaging guidance, you would report 10022 (... with imaging guidance).

If you are coding the pelvic ultrasound, you'll need to decide whether it was complete or limited.

Complete: Code 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) requires "description and measurements of the uterus and adnexal structures, measurement of the endometrium, measurement of the bladder (when applicable), and a description of any pelvic pathology (e.g., ovarian cysts, uterine leiomyomata, free pelvic fluid)," for female patients, according to CPT® guidelines.

Limited: Code 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or followup [e.g., for follicles]) is appropriate for a "focused examination limited to the assessment of one or more elements listed in code 76856 and/or the reevaluation of one or more pelvic abnormalities previously demonstrated on ultrasound."

Warning: You shouldn't report ultrasound separately if the record doesn't include "thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report," according to CPT®.

ICD-9 tip: If at all possible, wait until you have the pathology report to choose your diagnosis code.