Radiology Coding Alert

If 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.

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.

Once 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, percutaneous core needle).

Speed tip: To quickly locate an exact core biopsy code, look up "needle biopsy" in CPT's index. Find the anatomical location the radiologist biopsied, such as "lung," and you'll find the code: 32405 (Biopsy, lung or mediastinum, percutaneous needle). Be sure to double check the code in the manual to be certain you have the most appropriate option.

Whether you're reporting FNA or core biopsy, you'll choose from the same guidance code options, depending on modality, Gregory says:

• 76942 -- Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

• 77002 -- Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)

• 77012 -- Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation

• 77021 -- Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation.

For image-guided percutaneous needle (core) biopsy, you may see ultrasound (76942) most often, although fluoro (77002) is common, too, Gregory says. And according to the ACR, CT (77012) can help in cases when the radiologist needs a better look at the anatomy, such as for patients with difficult to access lesions or unusual anatomy, or when he needs to plan a route to avoid vital structures, Gregory says, citing the ACR's Practice Guideline for the Performance of Image-Guided Percutanous Needle Biopsy (PNB) in Adults (http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/iv/pnb.aspx).

If the radiologist performs both an FNA and a core biopsy on the same lesion because the first procedure didn't yield an adequate sample, you need to know the Correct Coding Initiative (CCI) bundles the FNA codes into the biopsy codes. But in the situation described, you may override the edit, according to the National Correct Coding Initiative Policy Manual (version 13.3, III-13).

The official language: CCI states that "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."

You'll need to append modifier 59 (Distinct procedural service) to the FNA code, says Schad. And sequence the FNA after the core biopsy code.

Reality: Although both the AMA/ACR Clinical Examples in Radiology (Vol. 1, Issue 3) and CPT Assistant (August 2002) state that you may report both services if both are medically necessary, coders report that proving medical necessity for both services is tough. Be sure you have strong documentation to support a choice to override the edit, and be sure you follow payer guidelines.