Outpatient Facility Coding Alert

Published on Fri Oct 16, 2015 PDF

Question: The physician performed a fine needle aspiration and then a needle biopsy of the same lesion at the same session. Should I report both?

Virginia Subscriber

Answer: The answer depends on why the physician performed both procedures (and, as always, the individual payer policy).

For Medicare and other payers who follow Correct Coding Initiative (CCI) policies, you should report both services only if the fine needle aspiration (FNA) specimen isn’t adequate and therefore there is medical necessity for another type of biopsy. The CCI Policy Manual gives this rule in Chapter 3, Section 10 (www.cms.gov/NationalCorrectCodInitEd/).

Straight from the source: “Fine needle aspiration (FNA) (CPT® codes 10021 [Fine needle aspiration; without imaging guidance], 10022 [...with imaging guidance]) 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.”

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