Radiology Coding Alert

Question: How should we report a CT-guided needle adrenal mass biopsy?

Missouri Subscriber

Answer: If your radiologist performs a core-needle biopsy, you should report CPT 49180 (Biopsy, abdominal or retroperitoneal mass, percutaneous needle) with 76360 (Computerized tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation).

In unusual circumstances, the radiologist might collect fluid, which would warrant a fine-needle aspiration code. If the physician uses imaging guidance, report 10022 (Fine needle aspiration; with imaging guidance) along with an imaging guidance code.

If the radiologist performs the biopsy without radiologic guidance, choose 10021 (... without imaging guidance).