Radiology Coding Alert

You can know every trick in the book about properly coding aspirations and biopsies, but you still can be left guessing if the radiologist includes both terms in the documentation for a single service.

Take a look at a real life case provided by Dianne M.Nakvosas, ACS (RAD), senior coder at Compubill Inc. in Orland Park, Ill., and see how she used the case to explain to physicians the importance of clear documentation.

Nakvosas shared the following case with four doctors:

Nakvosas then presented the doctors with the following code options and asked them to choose the appropriate one:

21550 -- Biopsy, soft tissue of neck or thorax

20206 -- Biopsy, muscle, percutaneous needle

38505 -- Biopsy or excision of lymph node(s); by needle, superficial (e.g., cervical, inguinal, axillary)

10022 -- Fine needle aspiration; with imaging guidance.

Result: After a long pause, "one of the doctors finally responded," says Nakvosas. "He chose 38505. Then finally another doctor said, 'One of the top three, whichever one pays more.' The other two doctors did not respond." To add to the mix of guesses, the coder who got the report flagged the case for investigation but chose a preliminary code of 10022. "The actual report had a hospital generated code already on it of 21550," Nakvosas says.

The largest hurdle to choosing the proper code for this case is that it refers to both biopsy and aspiration.

Starting at the first line, the header is "CT-Guided Biopsy of a Left Neck Mass," says Nakvosas, so 21550 (neck soft tissue biopsy) may seem to make sense at first glance. But CPT's note under 21550 says that for a soft tissue "needle biopsy," you should use 20206 (muscle biopsy) instead, she says. So neither 21550 (non-needle biopsy) nor 20206 seem to fit this case. Plus, experts agree that you shouldn't choose a code based on the report header alone.

Moving on, the Procedure section states, "Under CT guidance, a 21-gauge needle was inserted into the enlarged left internal jugular lymph node." Based on this quote, you might add 38505 (lymph node needle biopsy) to your list of contenders, Nakvosas says. But the next sentence refers to "two aspirates," which suggests 10022 (aspiration). The Impression section ("CT guided aspiration ...") also points to 10022, Nakvosas says.

Experts warn: The 21-gauge needle doesn't solve the riddle because needle size does not determine whether the service is a fine needle aspiration (FNA). Although a fine needle is more common for aspiration and a larger cutting needle is more common for obtaining a core tissue sample, "any size needle can be used," states the "ACR Coding Source" article in the March 2006 ACR Bulletin.

Nakvosas, who is certified and has been coding 11 years, quickly zooms in on the dilemma: "I want 38505 because of the terms used: biopsy, lymph node, needle, cervical. But because the impression states aspiration, perhaps it should be 10022. This is why the doctors need to be very clear in their dictation. This particular report can be interpreted either way, and that is why there is such a gray area in this field. If the doctors couldn't interpret it, how are we to interpret it?" she concludes.

Nakvosas explained to the physicians the importance of crystal clear documentation. For this case, her focus was whether the doctor obtained cells or tissue so the coder could decide between aspiration and biopsy. Coders can't assume the role of doctor and guess the precise service, she stresses.

Definitions: Aspiration typically takes a small sample of cells or fluid, while a core biopsy takes acore tissue sample rather than a few cells, the ACR Bulletin article states. Because of this difference, aspirate samples go to pathology for cytologic examination. Core biopsy samples, on the other hand, undergo histologicevaluation.

CPT Assistant, August 2002, offers similar definitions in discussing a lung service: "32405 [Biopsy, lung or mediastinum, percutaneous needle] describes a percutaneous needle biopsy, in which a small piece of tissue is taken through the needle and examined for histologic architecture. Code 10021 [Fine needle aspiration; without imaging guidance] describes a fine needle aspiration, in which fluid or tissue is aspirated with a long, slender needle and the cells are examined cytologically."

Lesson: Creating a common understanding of the terms with your radiologist can help ensure his dictation supplies the information you need for proper coding.

In all the aspiration vs. biopsy confusion, don't forget to code the radiological guidance, too. When you're reporting FNA (10022), you'll choose from these guidance code options, depending on modality, says Stacy Gregory, CPC, CCC, RCC, of Gregory Medical Consulting Services in Tacoma, Wash.:

76942 -- Ultrasonic guidance for needle placement

77002 -- Fluoroscopic guidance for needle placement ...

77012 -- Computed tomography guidance for needle placement ...

77021 -- Magnetic resonance guidance for needle placement ...

A note under 38505 indicates that you should consider 76942, 77012, and 77021 for radiological guidance with that biopsy service.

Proper code: The sample report specifies CT guidance, so you should report 77012.

Note: Do you have a coding success story you'd like to share? Send your triumphs to deborahd@inhealthcare.com, and we may feature your story in a future issue.