Oncology & Hematology Coding Alert

Let's get right to the "core" issue here. Can you get paid for 38220 (Bone marrow aspiration) and 38221 (Bone marrow biopsy, needle or trocar) at the same site on the same patient? Nope, not even with modifier -59 (Distinct procedural service).

Further, recent Correct Coding Initiative (CCI) edits bundle 38221 so that it includes both the biopsy and the aspiration. If an oncologist performs only a biopsy, then 38220 is your code. New 2003 CPT codes support the intent of CCI 8.3 edits by repunctuating 38220 (Bone marrow; aspiration only) and indenting 38221 (... biopsy, needle or trocar) under 38220.

Make no mistake: Medicare is holding the line on bone marrow codes. From Medicare's perspective, the biopsy and aspiration are the same because the two samples bone and marrow are drawn from the same incision and removed from the same site. Often, the same needle is used for both.

However, some warriors in the field have been rallying around an alternative standard for years. Arguing that as far as physician effort is concerned, bone marrow aspirations and biopsies even when carried out through the same incision require significant and separate amounts of risk and effort, they have repeatedly petitioned for more realistic coverage.

In published comments, the American Society of Clinical Oncology (ASCO) argued that "there is clearly more work and cost involved in performing both procedures than in performing only one of the procedures, and the CCI edit is unwarranted."

Across the country, coders like Lynn Richmond, RHIT, the business office manager at Iowa Cancer Care, are well acquainted with the problem. It's hard for the doctors to understand the insurer's logic, she says. "When doing an aspiration and biopsy together, the doctors know they're putting in twice the effort, so they don't like the payer to step in with what seems like an arbitrary definition."

And physicians take the position that after the aspiration, the original site has already been disturbed and they have to probe around under the skin for the biopsy, Richmond explains.

A proposed G code that includes the bone marrow biopsy plus aspirate would radically change the landscape, but so far it's a mythical beast.

"From what I've heard regarding the proposed G code, my understanding is that if it's done on the same side, the fee will be something higher than a biopsy but lower than a biopsy plus aspirate," says Samuel Silver, MD, PhD, medical director of the Cancer Center Network Initiative at the University of Michigan and member of the AMA CPT Advisory Committee.

ASCO has also recognized CMS' attempt to right the wrong with a proposed new G code but would prefer that CMS pay for concurrent bone marrow aspiration and biopsy procedures through the same incision by using the same payment rules as for other concurrent surgical procedures, i.e., 50 percent of the normal payment on the second procedure. ASCO has also requested that in calculating RVUs for the new codes, CMS should start with bone marrow biopsy (the more complicated procedure) and add additional time to that procedure not the other way around, as they now propose to do. Finally, ASCO has asked CMS to allow additional overhead amounts for indirect costs other than staff time into the proposed RVUs.

The battle over bone marrow codes isn't over yet, but for now, this is what a typical biopsy and aspiration scenario can offer your practice. A patient had a bone marrow aspiration and biopsy performed, which was coded as follows: