Radiology Coding Alert

CCI offers guidance to protect you from unexpected payback requests.

Breast biopsies may not always go as planned, but you still have to know how to code your radiologist's services.

Let our experts lead you through an example case so you can learn how to capture all the pay your physician deserves.

Start With the Scenario

Scenario: Based on mammogram findings of a lump in her right breast (upper inner quadrant), a Medicare patient presents to your radiologist in a facility for an ordered fine needle aspiration (FNA). "Physicians often use FNA to obtain cellular specimens from a breast mass for diagnosis," says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

For the FNA procedure, the radiologist inserts a thin needle into the breast mass using fluoroscopic guidance and uses the syringe to extract cells, which he sends to pathology for immediate evaluation for adequacy. The specimen returns as inadequate for diagnosis. The radiologist consults with the pathologist, who recommends a percutaneous needle core biopsy (PNB) of the lesion due to cellular artifacts. A percutaneous needle takes out tissue in the mass's core, explains Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

With an order from the treating physician, the radiologist immediately proceeds to perform a PNB of the lesion with imaging guidance, using a larger-bore needle to remove a core tissue sample from the lesion.

The pathology report returns a diagnosis of ductal carcinoma in situ (DCIS) from the needle core biopsy specimen. The radiologist supervises and interprets the fluoroscopy performed for both the FNA and the PNB. The radiologist completes the procedure by placing a localization clip to mark the biopsy site.

Work Your Way Through the Code Possibilities

Because the radiologist performed services described by a variety of codes, you need to determine whether bundling rules limit what you may report. The relevant codes for the individual services the radiologist performed are as follows:

• 10022, Fine needle aspiration; with imaging guidance
• 19102, Biopsy of breast; percutaneous, needle core, using imaging guidance
• 77002, Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
• +19295, Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration (List separately in addition to code for primary procedure).

Solution: If you're following Medicare rules for a service performed in a facility, you should code the radiologist's services for the entire encounter as:

• PNB: 19102
• FNA: 10022-59 (Distinct procedural service)
• Fluoro: 77002-26 (Professional component)
• Clip placement: +19295.

FNA charge: Medicare's Correct Coding Initiative (CCI) edits bundle 10022 as a column 2 code with 19102. But the CCI manual explains that you may override the edit when the FNA specimen is inadequate: "Fine needle aspiration (FNA) (CPT® codes 10021, 10022) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the other biopsy procedure code may also be reported with an NCCI-associated modifier" (Chapter 3, Section I.10).

You should check individual payer policies, however. Some payers may have a policy that you should report only the final procedure that results in a diagnostically viable specimen. That would mean reporting 19102 but not the FNA code.

Capture additional fees: Because the physician provides the supervision and interpretation of the fluoroscopic guidance, you should list the code (77002) with modifier 26. You also should capture the localization clip placement using +19295.

Diagnosis: You should report the DCIS as 233.0 (Carcinoma in situ of breast). Under ICD-10, you'll choose from 12 codes in the range of D05.- (Carcinoma in situ of breast).