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Streotactic Biopsy

Pessie Posted Wed 22nd of May, 2013 20:11:42 PM

88 year old woman, has 2 nodules to biopsy. Can we do 2 in one day for Medicaid, and how? We have:
19103 2x
19295 2x
G0206 2x
77031
what is the right way to code this for proper reimbursement.
Thanks

Pessie Posted Thu 23rd of May, 2013 21:54:29 PM

please reply to my request, Thanks

SuperCoder Answered Fri 24th of May, 2013 01:11:06 AM

Hi,

I am enclosing an article from the coding institute to help you. Please note this is a 2009 article so please omit 2009 values.

Sidestep common unit mishaps like a pro -- we’ll show you how.

Breast biopsy coding choices add up pretty quickly because your radiologist has options for various biopsy and imaging methods. And you may have to determine whether she performed clip placement, too. But you can nail stereotactic breast biopsy coding every time with these three easy to implement steps.

1. Use Key Words to Separate 19102 and 19103

When your radiologist performs a stereotactic breast biopsy, you first need to determine which biopsy code to report. You’ll have to decide between 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) and 19103 (… percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance) based on the documentation your radiologist provides.

How to choose: "The difference between 19102 and 19103 is that 19102 is only the needle core biopsy using imaging," explains Karen Caputo, CCS-P, certified coder for the University of Toledo Physicians in Ohio. You’ll see the radiologist use a different device (also with imaging) for 19103.

19102: You’ll use 19102 when your physician documents that he simply inserts the device and then pulls out a core of tissue, says Laura Singleton, billing specialist at the Center for Surgery & Breast Health in Joliet, Ill. Keep in mind that your physician may make several "passes" in order to ensure that he has obtained a sufficient sample for pathology, Singleton adds.

Key: For both 19102 and 19103, report one unit per lesion -- not per sample -- unless your payer tells you otherwise in writing.

19103: Code 19103, like 19102, reflects a percutaneous procedure, but for 19103 the physician uses a "more sophisticated device that has suction or a rotating action to obtain the sample," Singleton explains.

For example, the radiologist may use a Mammotome device, which vacuums, cuts, and removes tissue samples.

"Generally 19103 is the code to use for stereotactic biopsies because of the automated vacuum assisted or rotating device that is used," says Pat McCullough, CPC, in the billing/coding department at Spring Ridge Surgical Specialists in Wyomissing, Penn.

Boost Biopsy Coding With NCD Know-How

Medicare’s national coverage determination (NCD) for "Percutaneous Image-Guided Breast Biopsy (220.13)" states, "Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for a radiographic abnormality that is nonpalpable and is graded as a BIRADS III [probably benign], IV [suspicious abnormality], or V [highly suggestive of malignant neoplasm]."

The NCD also states that "Medicare covers percutaneous image guided breast biopsy using stereotactic or ultrasound imaging for palpable lesions that are difficult to biopsy using palpation alone. Contractors have the discretion to decide what types of palpable lesions are difficult to biopsy using palpation."

Don’t overlook: Payers may add additional helpful guidelines, such as "When multiple lesions are involved; billing is dependent on the location of the lesion and the number of lesions. Documentation in the patient’s progress notes must indicate that the separate lesions are independent of each other, and that each biopsy is medically necessary." You can find this in the WPSIC document "Percutaneous Image-Guided Breast Biopsy" (RAD-028) available at www.wpsic.com/medicare/part_b/policy/rad028.pdf.

2. Capture an Extra $195 for 77031

For the "stereotactic" part of a stereotactic breast biopsy, look to code 77031 (Stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation). Note that you may report 77031 for "each lesion."

This code has 5.4 global transitioned facility relative value units (RVUs). Multiply that by the 2009 conversion factor (36.0666), and you see that Medicare offers roughly $195 for the global service. Even if you bill only the professional service (modifier 26, Professional component), you’ll receive roughly $80 (2.25 RVUs).

What it is: For stereotactic imaging, the radiologist takes images from two angles to visualize the biopsy path for the needle. The patient may be face down on a special, raised table which has an opening for the breast, allowing the radiologist to perform the biopsy from beneath the patient. Or the radiologist may use upright stereotactic imaging instead, particularly to biopsy the axilla of the breast. For upright imaging, the patient must sit in a chair or lie on her side.

Watch for: Sometimes radiologists work with a surgeon for stereotactic biopsies. The surgeon performs and reports the biopsy (19103) and the radiologist will report the guidance (77031).

3. Watch for Other Reportable Services, Too

If the radiologist performs a breast biopsy with clip placement, don’t forget to report +19295 (Image-guided placement, metallic localization clip, percutaneous, during breast biopsy).

Tip: If the radiologist performs the breast biopsy using stereotactic guidance, payers include a follow-up mammogram in the guidance codes. So if the radiologist performs a follow-up mammogram to confirm clip placement, you should not report the mammo-gram separately.

*************************************************************************************************************

Code 19102, Biopsy of breast; percutaneous, needle core, using imaging guidance, and code 19103, percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance, are reported based on the number of sampled lesions, not the number of obtained samples taken for pathological analysis.

Since malignant cells may be found in one area of a lesion but not in another, multiple passes into the same lesion may be taken in order to ensure that the lesion is appropriately evaluated. For example, if one lesion was sampled three times, the breast biopsy code 19102 would be reported once.

If ultrasound guidance was used for this breast biopsy procedure, then it would be appropriate to report code 76942, in addition to the breast biopsy code. Although the descriptors for codes 19102 and 19103 state "using imaging guidance," the guidance is reported separately (see the cross-reference notes below these codes). Code 76942 includes any preliminary ultrasound performed to confirm the lesion and plan an optimal biopsy approach, on the same day.

Pessie Posted Mon 27th of May, 2013 13:40:04 PM

although this article addresses multiple lesions involved in stereotactic biopsy, I do not see an answer on how to "code" it for proper reimbursement. We are missing something, and cannot figure how to get more than one lesion paid for Medicaid patients. Can you clearly specify? Your help is greatly appreciated. Thanks

Pessie Posted Mon 27th of May, 2013 13:40:43 PM

stereotactic

SuperCoder Answered Tue 28th of May, 2013 18:13:40 PM

Medicaid is state-administered so rules vary quite a bit. You should report as indicated (1 unit per lesion), but it's possible the payer has its own rule. The other thing I see is that the list includes a mammogram code and payers using CCI wouldn't allow that on biopsy/clip day (as stated in CCI manual, chapter IX: "If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with radiologic guidance (e.g., 76942, 77012, 77021, 77031, 77032), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging required to perform the procedure.")

Pessie Posted Wed 29th of May, 2013 23:48:29 PM

We just received a letter stating that we should resubmit with appropriate modifier. We used modifier 59 on cpt 10022 when billed with 19102. Is the 91 modifier appropriate? Thanks alot

Pessie Posted Thu 30th of May, 2013 23:48:55 PM

PLEASE REPLY TO THE ABOVE

SuperCoder Answered Fri 31st of May, 2013 01:53:47 AM

CCI offers guidance to protect you from unexpected payback requests.

Breast biopsies may not always go as planned, but you still have to know how to code your radiologist's services.

Let our experts lead you through an example case so you can learn how to capture all the pay your physician deserves.

Start With the Scenario

Scenario: Based on mammogram findings of a lump in her right breast (upper inner quadrant), a Medicare patient presents to your radiologist in a facility for an ordered fine needle aspiration (FNA). "Physicians often use FNA to obtain cellular specimens from a breast mass for diagnosis," says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

For the FNA procedure, the radiologist inserts a thin needle into the breast mass using fluoroscopic guidance and uses the syringe to extract cells, which he sends to pathology for immediate evaluation for adequacy. The specimen returns as inadequate for diagnosis. The radiologist consults with the pathologist, who recommends a percutaneous needle core biopsy (PNB) of the lesion due to cellular artifacts. A percutaneous needle takes out tissue in the mass's core, explains 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.

With an order from the treating physician, the radiologist immediately proceeds to perform a PNB of the lesion with imaging guidance, using a larger-bore needle to remove a core tissue sample from the lesion.

The pathology report returns a diagnosis of ductal carcinoma in situ (DCIS) from the needle core biopsy specimen. The radiologist supervises and interprets the fluoroscopy performed for both the FNA and the PNB. The radiologist completes the procedure by placing a localization clip to mark the biopsy site.

Work Your Way Through the Code Possibilities

Because the radiologist performed services described by a variety of codes, you need to determine whether bundling rules limit what you may report. The relevant codes for the individual services the radiologist performed are as follows:

10022, Fine needle aspiration; with imaging guidance
19102, Biopsy of breast; percutaneous, needle core, using imaging guidance
77002, Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
+19295, Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration (List separately in addition to code for primary procedure).
Solution: If you're following Medicare rules for a service performed in a facility, you should code the radiologist's services for the entire encounter as:

PNB: 19102
FNA: 10022-59 (Distinct procedural service)
Fluoro: 77002-26 (Professional component)
Clip placement: +19295.
FNA charge: Medicare's Correct Coding Initiative (CCI) edits bundle 10022 as a column 2 code with 19102. But the CCI manual explains that you may override the edit when the FNA specimen is inadequate: "Fine needle aspiration (FNA) (CPT® codes 10021, 10022) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the other biopsy procedure code may also be reported with an NCCI-associated modifier" (Chapter 3, Section I.10).

You should check individual payer policies, however. Some payers may have a policy that you should report only the final procedure that results in a diagnostically viable specimen. That would mean reporting 19102 but not the FNA code.

Capture additional fees: Because the physician provides the supervision and interpretation of the fluoroscopic guidance, you should list the code (77002) with modifier 26. You also should capture the localization clip placement using +19295.

Diagnosis: You should report the DCIS as 233.0 (Carcinoma in situ of breast). Under ICD-10, you'll choose from 12 codes in the range of D05.- (Carcinoma in situ of breast).

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