Radiology Coding Alert

One of the benefits of interventional radiology breast biopsies is quick patient recovery. Use these four steps to ensure your practice recovers their reimbursement with the same speed.

Interventional radiology procedures of the breast provide a minimally invasive alternative to traditional open procedures, offer patients the option of being treated on an outpatient basis, and present patients with more choices concerning the treatment they are being administered. And coding these interventional radiology breast procedures, i.e., imaging-guided percutaneous biopsy, postbiopsy clipped appointments, cyst aspirations, etc., also presents coders with more choices, options, and coding alternatives which isn't always a good thing.

"The majority of interventional procedures require at least two CPT Codes ," says April Brazinsky, CCS, coding specialist for the Community Hospital of the Monterrey Peninsula in California in a teleconference titled "Coding to Insure Proper Pay Up for Interventional Radiology Breast Procedures." Use these steps to guide yourself through coding breast biopsies and you can be sure you won't miss out on coding all of the components for which you should be reimbursed.

Step 1: Choose the Appropriate Surgical Code

"It is generally easiest to first determine what is being performed," Brazinsky says. She recommends using the basic procedural descriptor, i.e., biopsy or aspiration, to begin a search in the CPT index, then choosing the appropriate modality.

For a biopsy-specific example, a patient presents with a history of a nodule in her left breast, recorded by a previous mammogram. An ultrasound of the left breast confirms the presence of a nodule, and the patient and radiologist decide to carry forward with an ultrasound-guided core biopsy with a 14-gauge needle. Three separate cores are taken and submitted to pathology.

To choose the appropriate procedure code, first narrow your choices to only those codes representing a biopsy of the breast:

Of the possible breast biopsy codes, you can exclude 19100 and 19101 because the descriptors don't account for "ultrasound-guided" biopsies, those performed under ultrasonic guidance, a form of imaging guidance. Code 19101 can also be excluded because it represents an open rather than a percutaneous biopsy. Radiology practices typically won't encounter code 19100 because it does not require imaging guidance, Brazinsky says.

The procedure description did not mention the use of a vacuum or rotating device, so you can also exclude CPT code 19103. You have narrowed your search down to one code and should report code 19102 to represent the surgical component of the procedure.

Step 2: Apply Rules for Multiple Biopsies

When multiple biopsies are reported in the physician's operative report, coding the procedures can get complicated, says Mary Session, CPC, billing supervisor for Associated Billing Services in Phoenix.

Practices shouldn't see many claim denials for breast biopsies unless they are miscoding biopsies, Session says. She offers the following advice for coding multiple biopsies:

When a biopsy or biopsies are taken of multiple lesions, report multiple biopsy codes. For example, if the physician takes biopsies of two distinct lesions using ultrasonic guidance, you should report 19102 and 19102-59-51. Modifier -59 (Distinct procedural service) indicates to the payer that the biopsies were taken of separate lesions and modifier -51 (Multiple procedures) indicates to the payer that the multiple procedures payment reduction is applicable. "You may or may not want to append modifier -51 to the second biopsy code; however, if you don't append modifier -51 and you are submitting the claim to Medicare, the carrier will add modifier -51 for you," Session says.

As for claims being submitted to non-Medicare carriers, Sessions says that most insurance companies approve of modifier -51 on codes other than add-on codes, but you may want to check with your carrier.

If only one lesion is biopsied, regardless of the number of samples taken by the same method, report the surgical code only once. In other words, you can only bill a single surgical code for breast biopsies of the same method once per lesion. So if three biopsies are taken using ultrasonic guidance (19102), for example, but they are all taken of the same lesion, you should only report 19102 once.

If biopsies reported by the same CPT code are taken bilaterally, report the procedures separately. Different insurers will have different preferences for how bilateral breast biopsies are reported. For instance, if procedure 19102 is performed in both breasts, you may be required to report 19102 and 19102-51-59 as you would report biopsies of multiple lesions in the same breast. Other payers may require you to report 19102-RT and 19102-LT, making use of the HCPCS alpha-modifiers. And still other payers may require you to use the bilateral modifier -50 (Bilateral procedure), coding 19102-50.

"Carriers have quirky preference, and they all handle claims differently what is right with one carrier is not always right with another," Session warns, so it is a good idea to check with your carrier for its billing preference.

Step 3: Pick a Supervision and Interpretation Code

If we stick with the same example used to practice determining the appropriate surgical code and we assume that a single physician performed the biopsy and the radiological supervision and interpretation, our next step is to report code 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the ultrasonic guidance.

There are five types of "guidance" that a radiologist may use to perform a breast biopsy: stereotactic, mammographic, computerized tomographic, magnetic resonance, and ultrasonic guidance represented respectively by the following codes:

Even though the definitions of these codes indicate that they represent the radiologist's "imaging supervision and interpretation" it is important to append modifier -26 (Professional component) to the appropriate imaging code if the radiologist does not own the equipment or is providing the service(s) in a hospital setting, Sessions says.

"You can't report a single guidance code multiple times in a single patient encounter" if you are using that guidance to perform, for instance, multiple biopsies of a single lesion, Sessions explains. But if the radiologist is using different types of imaging during the patient encounter, perhaps ultrasonic guidance for a breast biopsy and stereotactic guidance for a cyst aspiration, you should report both code 76942 and code 76095. And don't forget to append modifier -26 to the guidance codes if the radiologist does not own the equipment.

Step 4: Check for Billable Supplies

"The majority of insurers won't pay for supplies including Medicare," Session says. The supplies are considered included in the procedure, she says, "however, there are some commercial insurance companies that will pay for supplies." When you report a radiologist's services performed in the hospital or another facility setting, never bill for the supplies, but when a practice that is involved in complete women's care, for example, performs a biopsy in a private office setting, ask your carrier whether there are any billable supplies, she says.