Urology Coding Alert

Don’t assume ‘biopsy’ always means the same thing.

When your urologist retrieves a specimen via a needle procedure, knowing the procedure specifics is the only way you can accurately determine whether you’ll report a fine needle aspiration (FNA) or a percutaneous needle biopsy (PNB) code.

Follow our experts’ three tips to make sure you always choose the correct code to represent your urologist’s work.

Tip 1: Watch Your Language 

Your surgeons may use “biopsy” as a universal term to mean that they took a sample of a specimen. That habit could lead you astray as you try to code these procedures. 

Better way: Encourage your surgeon to reserve “biopsy” for procedures that remove a small tissue specimen for diagnosis, whether open, laparoscopic, or percutaneous. If your surgeon is in that habit, you’ll know you really should look for the appropriate PNB code if the op note shows that a needle is involved. 

If the surgeon removes cellular material in an “aspirate” instead of tissue in a biopsy, turn to the FNA codes. 

Helpful hint: In urology, FNA may be used for aspiration of the testis or epididymis. Your urologist may also use PNB for these organs and for the prostate a transrectal or perineal PNB is almost always performed to obtain prostatic material for analysis.

However, if your surgeons continue to use contradictory language, a few hints will help you tell the procedures apart.

Tip 2: Procedures Have Own Sections

FNA and PNB are so different that CPT® actually places the procedures in separate sections.

FNA has its own codes, which are found in the integumentary section. CPT® defines these codes as:

• 10021 — Fine needle aspiration; without imaging guidance
• 10022 — ... with imaging guidance.

Don’t be fooled: You can use code 10022 even if your physician doesn’t actually perform the imaging guidance. The code simply indicates that the procedure required imaging guidance — the code does not include the imaging service. When image guidance is performed and billed by the physician performing the FNA, report an additional code from the radiology section, according to Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, director of reimbursement and advisory services, Altegra Health, Inc.

How to find PNB codes: Look for the anatomic site-specific surgery code.

Example: Your surgeon takes a percutaneous needle biopsy of the prostate. When you look in the genitourinary system under the subheading “incision procedures of the prostate,” you find 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach).

Speed tip: To quickly locate an exact PNB code, look up “needle biopsy” in CPT®’s index. Find the anatomical location the surgeon biopsied, such as the “epididymis,” and, presto, you can look up the specific CPT® code to ensure that it matches the procedure performed and documented. (For epididymis, you would use 54800, Biopsy of epididymis, needle).

Note: Your surgeon does not have to indicate the word “percutaneous.” Stating a “needle biopsy” in the procedure description is sufficient.

Tip 3: Biopsy Involves Larger Needle, Tissue Specimen

Other hints in the operative note that might help you distinguish a FNA from a PNB are the needle’s size and the specimen type. 

“A percutaneous needle is much larger than a fine needle,” reports Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Specimen: “A fine needle takes out an ‘aspirate,’ which is a sort of fluid that is sent to the pathologist for analysis,” Cobuzzi says. “A percutaneous needle is larger and takes out tissue in the mass’s core.”

Key terms: You should associate fluid or cell sampling with FNA and core or tissue sampling with PNB.

Mistakes could cost you: If you miscode a PNB as an FNA, you stand to lose significant pay. For instance, if you had reported the earlier prostate example as 10021 ($72.72 payment) instead of 55700 ($142.22 payment), that error would cost your practice $69.50 when performing these procedures in hospital and would cost your practice $74.30 when performed in office. 

Note: All payment values are based on the unadjusted Medicare Physician Fee Schedule with a conversion factor of 35.8228.