Radiology Coding Alert

You sent us your 76095 and 76096 questions - here are the answers

If you report breast biopsy guidance based on the number of punctures instead of the number of lesions, you are putting your reimbursement at risk of being slashed.

Get Paid for Services Provided

Scenario: Following an abnormal mammogram, a physician took core samples from three lesions in the left breast through two incisions. He removed two samples from each lesion. He took one core sample from one lesion in the right breast, making one incision, and he used mammographic guidance for each breast.
 
Helpful: Your first step is deciding which codes to report. This biopsy involves core samples, so choose CPT 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance), says radiology coding specialist Carrie Caldewey, CPC, RCC. If the report indicated Mammotome instead, Caldewey instructs you to report 19103 (... percutaneous, automated vacuum-assisted or rotating biopsy device, using imaging guidance).
 
Radiologists might also use a localization clip in this procedure. If the radiologist documents this service, report add-on code +19295 (Image-guided placement, metallic localization clip, percutaneous, during breast biopsy) in addition to 19102 or 19103, based on the number of lesions for which the radiologist used a localization clip.
 
You also know that mammographic guidance was the radiologist's method of choice. As a result, you report 76096 (Mammographic guidance for needle placement, breast [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation), says Deb Ovall, CMA, CCS, CIC, lead coder and data quality analyst with Medical College Hospitals of Ohio at Toledo.
 
The next step: Now that you know which codes to use, you must decide how to report them. For the left breast, the physician took a total of six samples from three lesions through two incisions. He produced one incision and one sample for one lesion on the right. You need to determine whether to code based on the number of samples, incisions, or lesions - and to do this, you must consult your carrier's guidelines. If no written guidelines are available, remember that coding conventions specify coding per lesion rather than per sample or incision.
 
For example, the coding guidelines from Empire Medicare in New York require the units of service for 19102 to be based on the number of lesions. The number of services for 76096 should also reflect the number of lesions. Empire insists that "regardless of the number of samples taken, the procedure should be coded per lesion." This requirement is the same for 76095 (Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation).
 
Just as for 76096, the descriptor for 76095 includes the phrase "each lesion," indicating that the American Medical Association intended these CPT codes to be used for each lesion.
 
Empire Medicare asks that the documentation show that the lesions you code for are independent of each other. You also need medical records that prove that each biopsy is medically necessary.

Make Modifiers Work to Your Advantage

What to do: Now that you have decided how many times to report the different codes, you need to determine which modifiers will be appropriate for your particular payer, Caldewey says.
 
One way: You may be able to simply bill 19102 and 76096 four times each (generally by reporting each code once with 4 in the units field for each).
 
Alternative: If your payer requires you to indicate lesions in the same breast with modifier -59 (Distinct procedural service) or modifier -51 (Multiple procedures), append it to the second and any subsequent reports of the code. You will also need to show that lesions from both breasts were biopsied.
 
Another option: If your payer wants you to report this as a bilateral procedure, append modifier -50 (Bilateral procedure). Your payer may prefer that you use the more specific -LT (Left side) and -RT (Right side) modifiers, particularly because you are reporting the biopsy of more than one lesion in the left breast. The bottom line is that you need to get your payer's preference in writing and follow it.
 
Example: For the scenario above, core samples from one right and three left breast lesions with mammographic guidance, you can report the following if your payer prefers modifiers -RT and -LT, recognizes modifier -59, and wants you to report guidance for each lesion using modifiers: 19102-RT, 19102-LT, 19102-LT-59, 19102-LT-59, 76096-RT, 76096-LT, 76096-LT-59, 76096-LT-59. Make sure the documentation supports that each lesion is independent (meaning noncontiguous) and each biopsy is medically necessary.