Radiology Coding Alert

For years, breast biopsies coding has been confusing because new procedures and equipment were implemented faster than applicable codes were added. Coders were forced to weigh multiple clinical factors and coding options to determine which mix of codes best described the services provided. This situation was clarified in 2001 when CPT Codes added and revised codes to better reflect current procedures and equipment.

Biopsies are performed using one of several techniques after an abnormality has been identified during a physical breast examination or by radiologist-performed mammography, which in some cases is followed by breast ultrasound. Areas with suspicious radiographic findings (e.g., lumps, masses, clusters of microcalcifications) are among the irregularities that are biopsied to determine malignancy.

Coding Breast Cyst Aspirations

If the ultrasound indicates that the abnormality is a cyst (i.e., fluid-filled), an aspiration may be performed. Aspiration is both a therapeutic and diagnostic procedure because fluid and cells are drained from the cyst (therapeutic) and sent to pathology for evaluation (diagnostic).

Although the procedures are virtually identical, two codes describe an aspiration. Typically, when the ordering physicians intent is for an aspiration only, a fine needle aspiration (88170, fine needle aspiration; superficial tissue [e.g. thyroid, breast, prostate]) would be used to report the procedure.

When the primary intent is for the radiologist to decompress a cyst with pathological analysis, coders may instead assign 19000 (puncture aspiration of cyst of breast) to the surgical component of the cyst aspiration. If more than one cyst is treated during the session, add-on code 19001 (... each additional cyst [list separately in addition to code for primary procedure]) would also be reported, according to Jacqui Szymanski, RT (R), M, practice administrator for Associated Imaging Specialists, a practice of six radiologists in Elgin, Ill.

The radiologist would be performing aspirations under ultrasound guidance, Szymanski notes, since ultrasound is the only modality that can differentiate between air and fluid, or a solid mass. This makes it ideal for locating a cyst. According to CPT 2001, coders would use 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). In the past, she says, coders would have assigned 76938, but that code has been deleted.

Percutaneous, Needle Core Breast Biopsies

When the mass is solid, the radiologist may perform a breast biopsy. Whether or not imaging is required, as well as what type of device is used, determines which of the biopsy codes will be assigned. CPT made modifications and additions to the codes in 2001, which made choosing a code much easier, says Edward Spiers, CPC, a coding specialist with the department of radiology at the University of Washington in Seattle.

Two of the four codes now in place identify biopsies performed by radiologists, while surgeons assign the other two. CPT codes 19101 (biopsy of breast; open, incisional), describing an open surgical procedure, and 19100 (biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]), describing a biopsy performed with a hollow needle inserted into a mass that can be physically located without using imaging modalities (e.g., a tangible lump), would be assigned by a surgeon.

Both the remaining biopsy codes (19102 and 19103) use imaging guidance, and a radiologist would perform these procedures. The difference between the two codes is the type of device used to perform the biopsy.

Code 19102 [biopsy of breast; percutaneous, needle core, using imaging guidance] is a procedure where a needle like a Tru-cut is inserted into the lesion. It is equipped with a small blade that extends and slices off a piece of tissue from within the mass. The tissue is withdrawn through the needle for testing, Szymanski says.

Code 19103 (biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance), on the other hand, represents a more complex device and technique, she notes. This provides more effective sampling. The device is a suction mechanism that may be rotated 360 degrees once it has been inserted into the mass. This allows the radiologist to take multiple samples from various locations within the lesion. It is a more accurate diagnostic tool. The devices used often are identified by their brand names in the operative report (e.g., Mammotome or ABBI). Szymanski notes that, when these names appear, coders automatically know to assign 19103.

These codes may be accompanied by an imaging code to describe the guidance modality used. In addition to 76942, these include:

76095 stereotactic localization guidance for breast biopsy or needle placement (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation;

76096 mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation.

Although less common, CT or MRI may be used during a biopsy. In this case, 76360 (computerized tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device] radiological supervision and interpretation) or 76393 (magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation) would be assigned.

Szymanski notes that stereotactic guidance used extensively with 19103 is fast becoming the modality of choice because it provides an accurate, three-dimensional image. This allows the radiologist to better gauge the depth of the mass and position the needle precisely to collect samples that best represent the nature of the tissue.

These new codes have eliminated confusion that had dogged biopsy procedures in the past. Coders needed to understand whether or not lesions were palpable, and how CPT defined incisional. These issues have been put to rest with the new language, thankfully, and our jobs are a little easier now, Spiers says.

According to CPT, the surgical codes may be assigned once for each lesion biopsied but not for each pass that the needle or sampling device makes within each lesion. If multiple lesions are biopsied, modifier -51 (multiple procedures) should be added to the second or subsequent code. Also, these codes are unilateral and if lesions on both breasts are sampled, the codes should be reported twice with modifier -50 (bilateral procedure), or the -RT/-LT designation. However, as is always the case when using CPT modifiers, your local payer policy prevails.

Coding Clip Placement

If a clip or marker is placed near the lesion during a biopsy, Spiers says, code 19295 (image guided placement, metallic localization clip, percutaneous, during breast biopsy [list separately in addition to code for primary procedure]) would be assigned in addition to the biopsy and guidance codes. Medicare considered 19295 to be bundled into the procedure performed, although some commercial payers allow separate reimbursement for clip placement.

Coders should note that there is a typographical error in the 2001 CPT manual regarding this code, however, Spiers says. A parenthetical note erroneously indicates that 19295 should be reported with 19102. CPT Assistant has affirmed that it should be assigned with 19103.

When an Aspiration Becomes a Biopsy

On occasion, Szymanski says, a radiologist will perform an aspiration and, once the fluid has been drained, discover a solid mass. You wouldnt walk away from this situation, but would call the originating physician for an order to perform a biopsy, as well. If both procedures were conducted, both the aspiration and the appropriate biopsy code would be reported, she says. You would append modifier -59 (distinct procedural service) to identify the two services.

But, if a biopsy is performed because no fluid could be obtained during an aspiration attempt, the radiology practice would bill only for the biopsy.

The American College of Radiology says CPT 76098 (radiological examination, surgical specimen) may be coded in addition to the base procedure if radiographs of the biopsy specimen are performed to ensure the tissue contains a sample of the abnormality.