Radiology Coding Alert

Question: The physician performed a fine needle aspiration and then a needle biopsy of the same lesion at the same session. May I report both?

Codify Member

Answer: The answer depends on why the physician performed both procedures (and, as always, the individual payer policy).

For Medicare and other payers who follow Correct Coding Initiative (CCI) policies, you should report both services only if the fine needle aspiration (FNA) specimen isn't adequate and therefore there is medical necessity for another type of biopsy. The CCI Policy Manual gives this rule in Chapter 3, Section 10 (www.cms.gov/NationalCorrectCodInitEd/).

Straight from the source: "Fine needle aspiration (FNA) (CPT® codes 10021 [Fine needle aspiration; without imaging guidance], 10022 [...with imaging guidance]) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis. For example, 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."

Alternative: CPT® Assistant (August 2002) gives a different view in a Q&A about lung biopsy, indicating that because a percutaneous needle biopsy and FNA are distinct procedures, "it would be appropriate to report both codes together." The Q&A suggests adding modifier 51 (Multiple procedures) to the secondary procedure. But it also recommends checking with the payer for its reporting guidelines and following those rules.

RS&I: Remember that you may report radiological supervision and interpretation (RS&I) in addition to the biopsy. For example, you should report 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for ultrasound guidance.