Outpatient Facility Coding Alert

Question: One of our surgeons documented, "Cyst aspiration ... clear yellow serous fluid was removed from the left breast cyst ... send the specimen for cytology with strong family hx of breast cancer." The pathology report reads, "Surgical procedure reads: specimens: a fine needle aspiration of left breast cyst." Should we report code 19000 or 10021?

Florida Subscriber

Answer: The correct choice is 10021 (Fine needle aspiration; without imaging guidance).

Explanation: Fine needle aspiration is a diagnostic procedure that involves collecting an "aspirate" (a small amount of cells, tissue, or fluid) from a cyst or mass. Because no imaging guidance is used, the physician might make several attempts before obtaining an adequate specimen. The physician completes the procedure with the intent of sending the aspirate to the lab for analysis. In this situation, the physician requested lab tests because of the patient's family history of breast cancer. The current national facility payment rate for 10021 is $70.46.

Comparison: When the physician's primary objective is to treat the cyst rather than biopsy its contents, 19000 (Puncture aspiration of cyst of breast) might apply. The physician inserts a needle into the cyst and withdraws fluid from it. He may or may not send the fluid to a lab for analysis, depending on the patient's history. The national facility payment rate for 19000 currently is $43.57.