Radiology Coding Alert

Question: I have a thyroid aspiration and biopsy that I'm not sure how to code. The operative report reads in part: "After infiltration of a local anesthetic, a 21g needle was positioned within the left lobe of the thyroid gland using US guidance. A fluid aspiration biopsy was obtained. Three such aspiration biopsies were obtained. The patient tolerated the procedure well, etc."

Would I code this procedure 60001 (Aspiration and/or injection, thyroid cyst) and 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation), or 10022 (Fine needle aspiration; with imaging guidance) and 76942?

New York Subscriber

Answer: Coders often have trouble distinguishing between biopsies obtained as an aspirate and core biopsy samples. The difference between the two procedures is that a fine needle aspiration (FNA) is performed by drawing up fluid and/or cellular aspirate with a long slender needle to evaluate the cells cytologically, while a biopsy uses a needle (gauge or size is unimportant in the distinction) to remove a small tissue core specimen whose composition is then examined as an intact tissue sample with or without attendant cytological analysis.

You use 60001 or 60100* (Biopsy thyroid, percutaneous core needle) only if the report makes specific mention of a core biopsy's being performed. This core biopsy could be performed with any gauge needle and may or may not also be accompanied with an aspiration biopsy. Also note that the parenthetical notes under codes 60001 and 60100 direct you to 10021 or 10022 for FNA.

Since the report dictated that three fluid aspirations were obtained and makes no mention of a core biopsy, your best bet in this case is 10022 and 76942. But this case underscores the importance of specific and detailed procedural reports even in relatively simple and straightforward interventions such as biopsies and aspirations.

Therefore, as a side note, you may want to talk with your radiologists about the finer shades of meaning in his or her dictation regarding aspiration, biopsy and FNA. When your radiologists generalize and call a procedure such as this one an "aspiration biopsy," they are not using the most precise terminology, thus putting you in the position of either interpreting their intent (not a good idea) or asking for clarification every time you see the term.

It would be advisable to establish a protocol such that your radiologists' operative reports clearly reflect the variety of CPT codes available to them by specifically stating that an aspiration was performed, or a core biopsy was performed, or a core biopsy in conjunction with an aspiration was performed. The term "fine needle" does not differentiate among these services because any and all of them (including a core biopsy) can be performed with a fine needle.