Otolaryngology Coding Alert

CPTs introduction of 10021 (Fine needle aspiration; without imaging guidance) and 10022 ( with imaging guidance) and deletion of 88170 (Fine needle aspiration; superficial tissue [e.g., thyroid, breast, prostate]) and 88171 ( deep tissue under radiologic guidance) should help alleviate some confusion over fine needle aspiration (FNA) coding and billing.
 
FNA, used to obtain a specimen from an expanding, nonvisible neck, thyroid, parotid or submandibular mass, differs from a needle core biopsy (another procedure used to obtain such a specimen) in that FNA relies on a fine needle (typically 18-25 gauge) to draw cells and fluid from the mass rather than the tip of a needle to collect tissue. Imaging guidance is used to accurately locate the mass, primarily for nonpalpable or cystic lesions. A histology report is not required for an FNA; instead, a cytology report must be included in the patients chart. FNA may be performed because it is less likely to harm the patient than a needle core biopsy or because a more extensive biopsy cannot be taken. The FNA may not collect enough of the specimen to determine a diagnosis, making a more extensive biopsy necessary.
 
Although there is nothing inherently unusual about FNA from a clinical standpoint, the same cannot be said about coding and billing this procedure, says Elaine Elliott, CPC, a coding and reimbursement specialist in Jensen Beach, Fla.

Relocation in CPT Manual

 
One cause of coding confusion was the fact that until Jan. 1, 2002, CPT listed FNA services among codes in the Pathology and Laboratory section (80000 series) rather than the Surgery section (10000-69990 series).
 
Many otolaryngology practices incorrectly coded FNA procedures either because they did not know of the existence of 88170-88171 (as they were listed in the Pathology and Laboratory section rather than the Surgery section of the CPT Manual) or because they were uncertain about coding and billing guidelines for pathology/laboratory services.
 
For example, the otolaryngologist would perform an FNA to obtain a specimen from a lymph node and report 38505 (Biopsy or excision of lymph node[s]; by needle, superficial [e.g., cervical, inguinal, axillary]). For image guidance, one of the following radiology codes was erroneously reported: 76360 (Computerized axial tomographic guidance for needle biopsy, radiological supervision and interpretation), 76393 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation]) or 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). FNA of the salivary gland was often reported using 42400 (Biopsy of salivary gland; needle) and thyroid FNAs were incorrectly reported using 60001 (Aspiration and/or injection, thyroid cyst) or 60100 (Biopsy thyroid, percutaneous core needle).
 
This coding strategy left the otolaryngology practice free from concern about pathology/laboratory guidelines, clinical laboratory improvement amendment numbers and the like. Unfortunately, it was also incorrect, Elliott says, adding that the new codes in the 10000 series should be much easier to find and understand.
 
By moving the FNA codes to the Surgery section, CPT has eliminated a lot of confusion, says Elliot.

Professional Versus Technical Components

 
Codes 88170-88171 were broken down into professional and technical components, leaving some otolaryngology practices unclear about which components were performed by whom, notes Randa Blackwell, financial specialist with the Department of Otolaryngology-Head and Neck Surgery at the University of Maryland in Baltimore.
 
Although many coders expected the breakdown into professional and technical components to disappear with the demise of 88170-88171, it lives on with 10021-10022.
 
The professional component, which includes placing the needle and drawing the sample, is reported as 10021 or 10022 with modifier -26 (Professional component) appended.
 
The technical component is coded based on whether the FNA is performed at the hospital or in the physicians office. The otolaryngologist performing at the hospital could not charge for the technical component; thus, the physician would code 10021-26 and leave billing for the technical component to the hospital. The otolaryngologist performing in the office would use the global code (including both technical and professional components) without appending modifier -26.
 
Note: Neither component involves the cytology report, which the pathologist reports separately using 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report). The technical component in this procedure consists of little more than providing the supplies used.

Latest CCI Edits

 
Correct Coding Initiative version 8.0, in effect Jan. 1-March 31, 2002, bundles 10021 and 10022 with 42400 and 60001 and assigns both edits a 1 indicator to suggest that they can be bypassed in certain situations.
 
For example, if the otolaryngologist obtains a needle core specimen from the right salivary gland and performs FNA on the left gland, both biopsies may be reported. Modifier -59 (Distinct procedural service) would be appended to the appropriate FNA code, as this is the lesser-valued procedure.