Radiology Coding Alert

1 tip lets you find core biopsy codes in a snapIf you have trouble telling the difference between a core biopsy and fine needle aspiration (FNA), you aren't alone. But you are at risk of miscoding the procedures. Here's the lowdown on how you should code each.
Biopsy Report = Core Biopsy Code?You know that you should use different codes for FNA and core biopsies. Unfortunately, your radiologist's notes may make determining which procedure he performed difficult.
Physicians may use biopsy as a universal term to mean that they took a specimen sample. If your radiologist is in this habit, you may miscode his procedures assuming he performed a core biopsy when he performed an aspiration. A few hints will help you know what you can and can't use to tell the terms apart.Needle size: Don't count on the needle size to tell you which procedure the radiologist performed. 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," stresses the ACR Coding Source article in the March 2006 ACR Bulletin.Sample type: Aspiration typically takes a small sample of cells or fluid, while a core biopsy takes a core tissue sample rather than a few cells, the ACR Bulletin states. Because of this difference, aspirate samples go to pathology for cytologic examination. Core biopsy samples, on the other hand, undergo histologic evaluation.If you are uncertain about which procedure the radiologist performed, be sure to verify before coding.Anatomic Location Matters for Core OnlyOnce you've identified the procedure, you need to choose the appropriate code. You report core biopsies according to anatomic site and also code for any guidance the radiologist uses, says radiology coding expert Cheryl Schad, BA Ed, CPC, ACS-RA, PCS, owner of New Jersey-based Schad Medical Management.For fine needle aspiration, you use 10022 (Fine needle aspiration; with imaging guidance) regardless of anatomic site, Schad explains. And you again report any guidance used, she adds.Exception: For fine needle bone aspirations, you should use 20615 (Aspiration and injection for treatment of bone cyst), Schad says. Remember to always choose the most accurate code CPT offers.Note: CPT offers another FNA code, 10021 (... without imaging guidance), but your radiologist is unlikely to perform FNA without guidance, says Stacy Gregory, RCC, CPC, of Gregory Medical Consulting Services in Tacoma, Wash.How to find core codes: Rather than having a single code for core biopsies, you need to look for the anatomic site-specific surgery code.
Example: A radiologist takes a core biopsy of the thyroid. When you look in the surgical section of the CPT manual under endocrine system and the subheading "thyroid gland," you find 60100 (Biopsy thyroid, [...]