Oncology & Hematology Coding Alert

Check for biopsy, append needed modifiers, and count units.

When reporting fine needle aspiration (FNA) code 10021 (Fine needle aspiration; without imaging guidance) or 10022 (Fine needle aspiration; with imaging guidance), you’ll be on track to earn your deserved payment if you know how many units to report and how to code when your physician also does a core biopsy.

Context: Fine needle aspiration (FNA) of a thyroid nodule can help to confirm the nature of the nodule and guide further evaluation and treatment plans.

Let the following example guide your coding.

Example: You may read that your physician performed FNA of the right thyroid and FNA of a nodule of the right thyroid isthmus. You further look at the pathology examination report and read that ‘Both specimens were inadequate for diagnosis.’ Following this, you see that your physician immediately performed a right thyroid core biopsy and a core biopsy of the right isthmic nodule at the same encounter as the FNA.

2 crucial questions: In this case, you encounter two prime challenges: (1) whether you should report biopsy with FNA, and (2) how many units of FNA and biopsy you should report. Here are tips to confront these challenges. 

You Can Report FNA and Biopsy Together

You’re allowed to report both the FNA and core biopsies to Medicare.  However, you must verify whether the documentation states that the FNA samples were inadequate.  If supported, you may append modifier 59 (Distinct procedural service) to the FNA procedure coded to override the Correct Coding Initiative (CCI) edit pair whether using 10021 or 10022 (depending on whether imaging guidance was used and documented or not) and the biopsy code.

Let’s assume imaging was used for the FNA in the example above. You would report 10022-59 (Distinct procedural service) and 60100 (Biopsy thyroid, percutaneous core needle). You should append modifier 59 to indicate that your physician performed the biopsies on separate and distinct anatomic areas, says Kristen Taylor, CPC, CHC; Managing Consultant with Altegra Health, Inc. in Los Angeles, California.

Support: The CCI manual states, “Fine needle aspiration (FNA) (CPT^® codes 10021, 10022) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis. 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 other biopsy procedure code may also be reported with an NCCI-associated modifier,” (Chapter 3, Section L.11, in the current manual, available at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html).

Payer alert: You should also check individual payer policies. Those who do not use the CCI edits and guidance may have a varying policy that you should report only the procedure that results in a diagnostically viable specimen.

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 CCI manual states - The unit of service for fine needle aspiration, CPT^® codes 10021 [Fine needle aspiration; without imaging guidance] and 10022 [Fine needle aspiration; with imaging guidance], 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 separate aspiration(s) of a distinct separately identifiable lesion.

In other words, you should tally how many lesions are being aspirated. You can report 10021 x 2 (or 10022 x2 if imaging guidance is used and documented) when aspiration is done on two separate lesions, says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Each separate lesion should be reportable for core biopsy (60100) as well, depending on payer policy. Keep in mind that some payers may require documentation to support reporting more than one biopsy.

In the example above, you would report 2 units of 10022 (since we are assuming imaging guidance was used) and 2 units of 60100. Payer rules may vary, so check with your payer; otherwise, these 2 units each for 10022 and 60100 should be acceptable in most circumstances.

Don’t Overlook the Imaging

When reporting 10022, you imply that your physician is using imaging guidance, as the descriptor of the code specifies ‘with imaging guidance.’

For the ultrasound guidance, the CCI manual, Chapter 9, Section G.3, states, “CPT^® codes 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation), 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]), 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]), 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation) and 77021 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation) describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections or number of localizations.” 

“While CPT^® code 77003 is included in this quoted guidance, it is not applicable to the example cited above as it relates to a therapeutic or diagnostic injection, not a biopsy procedure,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc.

On the other hand: CPT Assistant^® (April 2005) takes a different stance, stating, “From a CPT^® coding perspective, code 76942 should be reported per distinct lesion that requires separate needle placement.” So again, see what guidance your payers allow or require.

Conclusion: In the example case above, you may report units for the ultrasound guidance code 76942 depending upon payer policy. Medicare has in place a medically unlikely edit (MUE) unit of 1 for 76942. For other payers, you may be able to report 76942 once for each separate nodule biopsied and payor policy would dictate the rule used.