Radiology Coding Alert

Question: How should I code the visualization and aspiration of two cysts in the same breast?

New Jersey Subscriber

Answer: Because coding multiple cysts isn't the same as coding for multiple biopsies, many coders have trouble keeping the requirements straight.

Let's start by coding the surgical procedure, the aspiration of the cysts. The code for aspiration of cyst of breast, 19000* (Puncture aspiration of cyst of breast), is the code you are looking for, and you should note that it is for the aspiration of a single cyst. Although it may seem as if you will need to report 19000 with a modifier or with additional units in the units column of a claim, code 19000 is followed by an add-on code that should be reported for each addition cyst: +19001 (... each additional cyst [list separately in addition to code for primary procedure]).

So if three cysts in the breast were aspirated, you would code 19000, 19001 and 19001. And in your case, where only two cysts were aspirated, you should report 19000 and 19001.

Now let's code the guidance. Below the codes for the aspiration is a parenthetical note in CPT that states, "If imaging guidance is performed, see 76095, 76096, 76393, 76942." These imaging codes represent stereotactic, mammographic, magnetic resonance, and ultrasonic guidance respectively. The documentation should indicate the type of guidance used, but if not, you should ask your radiologist what form of guidance the aspiration was performed under.