Radiology Coding Alert

Answer: The key to this coding conundrum the motivating factor for the biopsy can most likely be found in the radiologist's documentation.

If the radiologist attempted to perform an aspiration but couldn't obtain fluid and subsequently decided to perform a biopsy, you can only report and bill the biopsy.

However, if the radiologist performed an aspiration, drained fluid, then discovered a mass that he felt needed to be biopsied and the radiologist received an order from the patient's attending physician to perform that biopsy, you can code both the aspiration and the biopsy with modifier -59 (Distinct procedural service) to break the bundling edit between the aspiration code and the biopsy code.

If the documentation does not indicate which of these scenarios has taken place, consult with the radiologist before determining how you should code what was performed.