Suzanne Posted Wed 16th of March, 2016 15:05:47 PM
Our surgical oncologist performs many steriotactic breast biopsies. My question is how to code the number of biopsies taken during one session. He dictates "....The trocar was prefired and then adjusted, correlating with the abnormalities where the markings had been placed. This required some further hand adjustments and repeat films. The biopsies were then eventually taken from every quadrant twice with two rotations. The specimens obtained were studied by confirmation films and we believe we were able to identify the microcalcifications....." Do I code for ONE biopsy (19081) or additional bx also (19082 +??? Difficult to "count" microcalcifications, in one area of the breast. Or is this considered one lesion, no matter how many biopsies are taken? Should I ask the doctor to specify how many lesions in a case like this? Thank you so much....I could not code without my friend supercoder and all of you.....
SuperCoder Answered Thu 17th of March, 2016 08:37:02 AM
Thanks for the Query
Cpt code 19081 is the correct code for one lesion and 19082 for each additional lesion found.
When more than one biopsy or localization device placement is performed using the same imaging modality, use an add-on code whether the additional service(s) is on the same or contralateral breast. If additional biopsies or localization device placements are performed using different imaging modalities, report another primary code for each additional biopsy or localization device placement performed using a different image guidance modality. For further assistance follow undermentioned link.
Suzanne Posted Tue 22nd of March, 2016 12:25:33 PM
Thank you for the information. My conclusion then is that I can use 19082 for additional bx taken from same breast, using same imaging modality. Past claims show that only one additional bx is paid for, even if he takes bx's from several areas of the breast.
SuperCoder Answered Wed 23rd of March, 2016 01:12:36 AM
Thanks for the Query
If additional biopsies are performed using different imaging modalities, report another primary code for each additional modality.The contralateral and each additional breast and each additional lesion image-guided biopsy are then reported with code 19082.