Pathology/Lab Coding Alert

Answer: The way the fine needle aspiration (FNA) extraction codes work is that you should report a parent code for the first FNA lesion extraction, and an add-on code for subsequent FNA extraction(s) for separate lesions on the same date of service.

That means you should report your case as 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion) and +10004 (… each additional lesion (List separately in addition to code for primary procedure)).

MUE: You should also note that the National Correct Coding Initiative (NCCI) includes a table of Medically Unlikely Edits (MUEs) that reflects the maximum number of units most of the properly reported claims for a particular code would have. NCCI asserts that these values are carefully calculated, so you shouldn’t need to override them very often. However, when the physician performs and documents a medically necessary number of services that exceeds this limit, you can sometimes override the MUE.

Code 10021 has an MUE of 1, which is one reason that your claim would be rejected. On the other hand, +10004 has an MUE of 3.

There’s more: To figure out which circumstances might call for overriding an edit pair, take a close look at the MUE table and see that it includes a column for “MUE Adjudication Indicator” (MAI). This provides guidance about what circumstances allow you to override an MUE limit for a given code. If the code has an MAI of “1,” the code is adjudicated on a claim-line basis, meaning that you can’t exceed the number of MUE units on a claim line. You are allowed to use one of the distinct-service modifiers (such as modifier 59 or the “X” modifiers) to override the edit if circumstances warrant.

An MAI of “2” means that the frequency limit is absolute for a date of service — you cannot override the edit with a modifier.

An MAI of “3” means that the frequency limit is based on the date of service, and Medicare will automatically deny any claims in excess of that limit, even if you use an appropriate modifier. However, Medicare will consider an appeal with appropriate documentation.

Code 10021 has an MAI of 2, meaning that you can never override the edit and report more than one unit of the code on a single date of service. This makes sense given the fact that CPT provides an add-on code (+10004) to report additional units of the FNA extraction service.

Resource: You can access the MUE table at www.cms.gov/ medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ ncci-medicare/medicare-ncci-medically-unlikely-edits).