Otolaryngology Coding Alert

Question: What is the proper way to code 10021 for a fine needle aspiration on the left side of the body, but on the face and also the neck (same side, different area)?

West Virginia Subscriber

Answer: You should bill CPT^® code 10021 (Fine needle aspiration; without imaging guidance) once for the left side aspiration and again for the face/neck area. Append modifier 59 (Distinct procedural service) to the second use of 10021 to indicate a separate aspiration in a different area. If the payer is Medicare, instead of using the 59 modifier, you can use the XS modifier (Separate structure) which refers to separate sites. Verify that your provider’s documentation clearly delineates the separate anatomic sites.