Radiology Coding Alert

Question: Our provider performed a bilateral ultrasound (US)-guided fine needle aspiration (FNA) biopsy of the breasts. The operative report goes into full detail for aspiration of the right breast, but only indicates that “a similar procedure was performed on the left side.” Is this enough documentation to support a bilateral procedure? If so, how should I report the codes?

Utah Subscriber

Answer: It’s not uncommon to find this kind of verbiage on a US-guided FNA biopsy report that indicates a duplicate procedure was performed contralaterally. While the general rule is the more documentation the better, this sort of documentation is not necessarily atypical and does not need to be addended in order to code the procedure bilaterally. You may want to let your provider know that best dictation practices include the details specific to each side — in particular for malpractice defense.

As for the procedure coding, you’ve got to take into account that 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion) has a medically unlikely edit (MUE) of 1. This means that you may only report one unit of 10005 on any given date of service (DOS). Reporting 10005 separately with modifiers LT (Left side) and RT (Right side) is inappropriate and will be flagged by the payer.

Consider the following CPT^® Assistant guidelines:

• “Codes 10004-10012 and 10021 may be reported only once per lesion sampled in a single session. When more than one FNA biopsy is performed on separate lesions at the same session, on the same day, and using the same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s).”

By these instructions, you will report 10005 with modifier RT for the first lesion of the right breast and 10006 (… each additional lesion (List separately in addition to code for primary procedure)) with modifier LT for the second lesion of the left breast.