Radiology Coding Alert

Question:

The descriptor for 19102 states "using imaging guidance." Does that mean imaging is included in 19102, or should I report it separately? Also, how should I determine how many units of 19102 to report?

Maryland Subscriber

Answer:

You may report imaging guidance separately, and you should report one unit of the biopsy code per lesion sampled.

Guidance: Code 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) states "using imaging guidance." But you can rest assured that you may report guidance separately because a note with the code instructs you to see the following codes for imaging guidance performed for 19102:

Units: You should report 19102 "based on the number of sampled lesions, not the number of obtained samples taken," according to CPT Assistant (March 2010). The radiologist may take multiple passes in the same lesion to increase the chances of finding any malignant cells that are present. So if documentation shows three samples from a single lesion, you should report 19102 once, CPT Assistant states.