Pathology/Lab Coding Alert

Here's how to avoid this coding red flag

Yes, you have to use a CPT surgery code when your pathologist extracts a needle bone-marrow biopsy specimen, but be careful which code you choose.

If you use 20220 or 20225 to report the service when your pathologist obtains marrow for hematological review or bone-marrow biopsy interpretation, your claim could go straight into the denied stack.

20220 Signals Bone, Not Bone-Marrow Specimen

When your pathologist extracts a bone-marrow specimen, don't let the terms "needle," "trocar" or "bone" confuse your code selection. A bone biopsy and a bone-marrow biopsy represent two different specimens, and you have to report the surgical code accordingly.

You would only use 20220 (Biopsy, bone, trocar, or needle; superficial [e.g., ilium, sternum, spinous process, ribs]) or 20225 (... deep [e.g., vertebral body, femur]) for a bone biopsy, not a bone-marrow biopsy. A surgeon, not a pathologist, typically performs bone biopsies.

The pathologist does not use a bone biopsy procedure "to get a bone-marrow sample for hematological evaluation," says Timothy Carter, MD, medical director for Rex Healthcare in Raleigh, N.C. Rather, a surgeon may perform the bone biopsy "to get a piece of bone for other purposes," he says.

Scenario: To determine the infecting organism in a patient with osteomyelitis, a surgeon uses a needle to remove a small sample of bone from the humerus near the site of infection. The surgeon reports the biopsy as 20225. The pathologist reports the biopsy exam as 88307 (Level V - Surgical pathology, gross and microscopic examination, bone - biopsy/curettings).

Use 38221 for Bone-Marrow Biopsy

Important: If you report the pathologist's exam of a bone-marrow biopsy with 20220 or 20225 for the specimen extraction, you'll raise a huge red flag.

When your pathologist uses a needle or trocar to obtain a bone-marrow specimen, you should use 38221 (Bone marrow; biopsy, needle or trocar) to report the work, says Cherie Sumner, outpatient coding supervisor for University of North Carolina Hospital in Chapel Hill.

Scenario: A physician orders a bone-marrow biopsy to examine a bone lesion. The pathologist extracts the marrow and performs a pathology exam and interpretation. In this case, you would report 38221 for the extraction and 88305 (Level IV - Surgical pathology, gross and microscopic examination, bone marrow, biopsy) for the exam.

Bone-Marrow Aspiration 38220 Stands Alone

Although a bone-marrow aspiration and a bone-marrow biopsy may both use a needle to extract a bone-marrow specimen, the procedures have different CPT codes. The biopsy involves extracting a core of bone- marrow tissue, while during the aspiration, the physician extracts bone-marrow cells in fluid. To report a stand-alone bone-marrow aspiration, use 38220 (Bone marrow; aspiration only).

You should also code the pathologist's exam of a bone-marrow aspiration differently than his exam of a bone-marrow biopsy specimen.

Do this: Use 85097 (Bone marrow, smear interpretation) to report the aspirate exam.

Watch Out for Aspiration and Biopsy Together

Sometimes a pathologist may perform both a bone-marrow biopsy and a bone-marrow aspiration for the same patient on the same day because the two specimens may provide complimentary diagnostic information.

Good news: You may be able to report both the aspiration and the biopsy on the same day, but you'll have to know if the pathologist took the specimens from the same or different incisions to select the proper codes.

If the pathologist took the specimens from different sites or at different times of day, you may be able to report both 38220 and 38221, Sumner says. But you must use modifier 59 (Distinct procedural service) to indicate that the aspiration and biopsy did not occur through the same incision.

Exception: If the pathologist takes a bone-marrow biopsy and aspiration at the same operative session through the same incision, you'll have to report G0364 (Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service) for the aspiration.

Example: The pathologist takes a trocar bone-marrow biopsy through a small incision over the left iliac crest. She also extracts bone-marrow aspirate through a separate needle inserted through the same incision. Report both 38221 for the biopsy and G0364 for the aspiration.
 
Watch for: The National Correct Coding Initiative bundles 38220 and G0364 as a mutually exclusive edit pair. You must choose one code or the other to describe the physician's bone-marrow cell extraction, based on whether the pathologist performed the aspiration with the biopsy (G0364) or as a stand-alone procedure (38220).