Scrutinize documentation for clues to code breast biopsies

 A patient with suspected breast cancer comes in for a biopsy. The physician’s procedure note is titled “Needle breast biopsy of right breast.” Which CPT code do you report?

Based on the title of the operative report alone, coders can’t select a code. They need more information, so they need to look at the details in the body of the physician’s report, says Stacie L. Buck, RHIA, CCS-P, RCC, CIC, president and senior consultant for RadRx in Stuart, Fla.
“It’s very important to pay attention to what’s in the body of the report and not just look at the header of the report,” Buck says.
Many different providers perform breast biopsies, but it is one area where documentation is lacking, Buck says. “Breast biopsies should be easy to code because we have so few codes to assign,” Buck says. In reality, breast biopsies aren’t easy because of incomplete documentation.
Type of biopsy
The main thing to look for is what type of needle biopsy did the physician perform—a fine needle aspiration or a core needle biopsy?
The difference between an aspiration biopsy and a core biopsy is what the physician is sampling. Sometimes coders want to look at the size of the needle and use that to determine what type of procedure the physician performed. The size or gauge of the needle does not determine the type of procedure, Buck says.
“If that’s something that you have been relying on, throw that out of your head,” she says. Coders can use the needle size as a piece of information to consider, but should not code based on that information alone.
Aspiration biopsy
In an aspiration biopsy, the physician uses a fine, thin needle to aspirate a small sample of cells or fluid and sends the sample to pathology for a cytologic exam. Fine needle aspirations are not site-specific.
Coders have two codes to use when reporting a fine needle aspiration:
  • 10021, fine needle aspiration without imaging guidance
  • 10022, fine needle aspiration with imaging guidance
Some things to look for in the operative report include a fine-gauge needle, such as a 22- or 25-gauge and a notation about obtaining fluid from cyst or cells. Again, be careful not to rely on the needle size alone to determine whether the physician performed a fine needle aspiration, Buck says.
Core biopsy
With a core biopsy, the physician uses a thicker, larger cutting needle, such as a 10, 11 or 14 gauge needle, to obtain a core tissue sample that he or she sends to pathology for a histologic evaluation. In a core biopsy procedure, the needle actually cuts a tissue sample.
The codes for core biopsies are divided into anatomical locations.
For a core needle breast biopsy coders would report either:
  • 19100, percutaneous, needle core, without imaging guidance
  • 19102, percutaneous, needle core, with imaging guidance
Physicians sometimes will place a clip after the procedure. In those cases, report add-on code 19295 (image guided placement, metallic localization clip, percutaneous, during breast biopsy) in addition to CPT code 19102.
If the physician makes an incision and performs an open biopsy, report CPT code 19101.
Many facilities rely on their chargemasters to bill biopsy services. That can create a problem because what the chargemaster bills is not always the same as the procedure the physician documented, Buck says.
“If you have these procedures coming off of your chargemaster, I highly recommend that someone audits the claims and takes a closer look at them if they are not being reviewed by an auditor or a coder,” Buck says.
Other core biopsy procedures
A physician may also perform a vacuum-assisted core biopsy (CPT code 19103). The problem is physicians don’t always document the use of the vacuum, Buck says.
“A lot of time as coders, we want to see that language in the report, but it isn’t always there,” Buck says. If the report doesn’t state vacuum-assisted biopsy, coders can look for the terms mammotome or MIBB (minimally invasive breast biopsy). Those terms will tell coders the physician performed a vacuum-assisted breast biopsy.
Vacuum-assisted biopsies are also used to treat calcifications, so that will be another clue coders can look for in the documentation, Buck says.
Another type of breast biopsy is the large code biopsy (CPT code 19103). This procedure is also referred to as an ABBI (advanced breast biopsy instrumentation).
In this type of biopsy, the physician removes a core of tissue using a circular oscillating blade that is advanced concentrically over the initial localization needle.
The large core biopsy will pull a larger sample than the vacuum-assisted biopsy, but both procedures are coded using the same code.
For both procedures, codes can also report the clip placement when performed, Buck says.
Multiple pass, multiple lesions
The physician may perform multiple passes of the same lesion or may biopsy multiple lesions at the same time.
When the physician performs multiple passes of the same lesion, report only one biopsy code regardless of how many passes the physician made, Buck says.
However, if the physician is biopsying multiple lesions, coders may be able to report them separately, depending on payer policies, Buck says. Some payers may stipulate that coders can only report one biopsy per organ. Payer policy will also determine which modifier coders append to the additional biopsies.
If a physician performs both a fine needle aspiration and a core biopsy of the same lesion, the fine needle aspiration is bundled into the core biopsy of the same lesion, Buck says. The two procedures are only bundled if they are performed on the same lesion. If the physician aspirates one lesion and performs a core biopsy on a separate and distinct lesion, the procedures are not bundled.
Documentation concerns
Hopefully, physicians specify whether they are performing a fine needle aspiration or a core biopsy, but they don’t always, Buck says. If the physician’s documentation does not include the specific procedure, look for key words in the body of the report.
“I always recommend going back to the physicians and educating them on the terminology,” Buck says. How coders interpret terminology may be a little different from how the physician interprets it clinically.
“We don’t want to tell them what language to use,” Buck adds. “We want to show them the importance of communicating clearly the work that they are doing.”
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