welcome i am terry tropin and today i'm presenting a lesson on cpt coding for fine needle aspiration biopsies let me start with information about myself i have a master's in healthcare administration informatics from the university of maryland global campus and have rhia and ccsp certifications i am also an ahima approved icd-10 trainer i've taught health information technology at montgomery college in maryland for over 20 years i've also written books on coding these books are study guides that summarize the coding guidelines my books include one on e m coding icd-10-cm coding icd-10-pcs coding and external clauses these are available on amazon first let's look at the differences between fine needle aspiration biopsies and other types of biopsies a fine needle aspiration biopsy abbreviated as fna uses a very thin hollow needle attached to a syringe it takes out small amounts of fluid cells or very small pieces of tissue these are coated with one zero zero zero four to one zero zero twelve and one zero zero twenty one note that these codes are just fine needle aspiration biopsies they don't say from which tissue it's taken it's just needle aspiration a core needle uses a hollow core needle to remove small samples of tissue in a cylindrical shape in a cylinder these are coated to the body area involved so each body area will have different codes for core needle biopsies an excisional biopsy uses a percutaneous through the skin excision this is also called a wide local incisional biopsy and this is to remove an entire tumor with some of the margins and this also is coded to the specific body area an incisional biopsy uses a percutaneous incision to remove small a small part of a large tumor and this is coded to the body area so fna biopsies are selected code accord to the factor fnas but also the type of guidance used other biopsies are selected in the body area found in a specific body area so here's an idea of what the needles used or the tools used for these biopsies are look like note that the fna needle is thinner and involves a syringe the core needle biopsy uses a hollow needle that is a little bit bigger and finally the excisional and excisional biopsies use a surgical instrument like a knife surgical knife not a needle many of the guidelines refer to modifier 59 so let's take a look at this modifier modifier 59 is entitled distinct procedural service you can see more about this in appendix a of your cpt book modifier 59 to indicate that the procedures are not bundled in a specific case so what that's fine but what is bundling bundling is rolling together smaller services into a larger related service only the larger service is coded this is referred to as the cpt global surgical package see the introduction to the surgery section of cpt for more information about the package an example of procedures included in a global package might be an excision removal of a tumor closure of the wound use of anesthesia local anesthesia only use the code for removal of the tumor not separate codes for each step involved in doing the procedure sometimes services that seem related are in this in a specific case not related this may be because they're performed on different sites or organ systems performed during different surgical sessions require separate incisions or excisions or therefore treatment of separate injuries so how are these used how's modifier 59 used in fine needle aspiration biopsies well it modifier 59 is used in these to indicate the procedures are performed on different lesions or use different modalities meaning types of guidance we'll talk about this more as we review the guidelines so in order to code correctly for our fine needle aspiration biopsies you ask these questions was guidance used was more than one lesion biopsies if more than one lesion was biopsied was the same type of guidance used for each and finally were the fine needle aspiration and core needle biopsies performed during the same sessions and if so were these on the same lesion or different lesions so the first question what is was guidance used the codes list specific types of guidance one zero zero two one no guidance one zero zero zero five ultrasone guidance one zero zero zero seven fluoroscopic guidance one zero zero zero nine c t guidance one zero zero one zero one one mr guidance these are referred to as primary code each of these have are paired with a an add-on code and the guidance in the um uh in the the guidelines the guidance and the guidelines are called modalities and that just means typos so for the um each one of those primary codes we saw before um there is an add-on code so this answers the question was more than one lesion treated during this surgical session all has to be same surgical session same day if there are additional lesions you use an add-on code and you had these are paired with the ones we saw before and you have of course the plus sign in front of them which indicates their add-ons so we have one zero zero zero four no imaging guidance one zero zero zero six ultrasone guidance one zero zero zero eight fluoroscopic guidance one zero zero one zero ct guidance and one zero zero one two mr guidance the next question is was the same type of guidance used for each lesion so there's multiple lesions and was the same type of guidance used in this case the answer is yes so in this case you list the primary code for the modality the guidance and its related add-on code for each additional lesion so here's an example fine needle aspiration three lesions with ultrasine guidance so you do the primary code 1005 for lesion number one one zero zero six for lesion number two and then one zero zero to six again for lesion number three and these all have the same type of guidance so here's the practice if you'd like to find the code on your own pause the video so this case is fine needle aspiration biopsy one lesion and the right lung and one lesion in the abdominal wall during the same surgical session both biopsies use magnetic resonance guidance so we're going to go back to those questions was guidance used was there more than one lesion if there was more than one lesion was it the same type of guidance for each and then were fna and core needle biopsy on the same session which is not the case here okay so let's answer the questions first was guidance used yes it was mr guidance was more than one lesion biopsy yes in the lung and in the abdominal wall if more than one lesion was biopsied using fna was the same type of guidance used for each yes and then the fna and coordinatable biopsy don't apply in this case so we end up with one zero zero one one primary code for the fna of the right lung and an add-on code one zero zero one two for the fna of the abdominal wall so you're gonna use the primary code which is this one and then the add-on code since both use the same type of guidance note that it doesn't matter that one was in the lung and one was in the abdominal wall the final aspiration biopsy codes are just for fna they're not by body area in other cases uh separate lesions are biopsied and different types of guidance are used so the guidelines for this is use the primary code for mod modality number one and then another primary code from a deli number two with the modifier 59. it doesn't matter at the guideline state if the lesions are ipsilateral or contralateral same side opposite side or if they're from a different organ system structure whatever doesn't matter since the codes themselves was the type of guidance you're not going to list an additional code for the guidance from the radiology section like beginning with 77 000. each fn code fna code already includes the guidance so it would be redundant it wouldn't get wouldn't provide any more information to um do that here's another practice fine needle aspiration biopsy of lesion in the right lung using mr guidance and fna biopsy of a lesion in the abdominal wall using ct guidance and again we're going to go through the questions this helps you focus on what you need to know in order to select a code was guidance used was more than one lesion more than one lesion same type of guidance and was fna and core needle biopsy done which is not done in this case we'll get to that later in the um video okay was guidance used yes more than one lesion biopsy yes we have one in the lung and one in the abdominal wall was the same type of guidance used no the lung used mr and the abdominal wall use ct and then this one we don't talk about coordinator biopsy yet so that one is not applicable so we end up with one zero zero one one for the fine needle action of the right lung and then 1009-59 that 59 modifier for the fna of the abdominal wall since each one uses a different modality and the rule says use primary codes for each with a modifier 59 note that it doesn't matter that the lesions were in different body areas one's in the lung ones at the abdominal wall doesn't matter so was the same type of guidance used for each lesion no sometimes there are three or more lesions and two of them use the same modality so some of the lesions had one modality but there was another one so what do you do sometimes there are three or more lesions and two of them use the same modality but another one uses a different one so you're going to use a primary code for modality number one then add-on code for that modality and then a primary code for modality two so here's another practice fine needle aspiration biopsy of two lesions in the right lung using mr guidance and one lesion at the abdominal wall using ct guidance and then again we asked these questions was guidance used was there more than one lesion are they using the same type of guidance okay let's move on was guidance used yes it's more than one lesion biopsied yes two in the lung and one of the abdominal wall same type of guidance well in the lung they used mr in the magnetic resonance in the abdominal wall they used ct and this one is not relative in this one okay another fine needle aspiration biopsy of two lesions in the right one lesion in the abdominal wall different modalities so we code one zero zero one one for the first fine needle aspiration of the right lung and then one zero zero one two for the second fna of the right lung because they're using the same modality they're using the mr and then you have 1009-59 for the abdominal wall since that used a different type of modality different type of guidance okay so then we move on far from surgeries including fnas only to what if they use an f a fine needle aspiration biopsy or needle biopsy during the same session same day while coding depends on whether both biopsies were on the same lesion or different lesions and off also on the modality used so if it's the same session same lesion same guidance you're going to use the primary code for the fna with the type of guidance that's in the code and then a code for core needle biopsy you're not going to code separately for the guidance for the core needle biopsy it's the same as the other one because this code includes the type of guidance so you're not going to report it again so here's a practice fine needle aspiration biopsy of the lesion and the right lung and coordinatable biopsy same lesion same session both using ct guidance and again we're going to go through the questions let me pause for a minute in case you want to do it on your own so was guidance used yes was there more than one lesion no if more than one lesion was the same guidance that's not applicable in this case um because it's same lesion same session same guidance and with fna and core needle biopsy in the same session same modality same lesion so you have the fna and the lesion using ct that's one zero zero zero nines primary code and then you have a core needle biopsy of the same lesion using ct32408 and note that a code under this states that guiding a note under this states that on guidance is included but because they're both using the ct guidance you wouldn't report the guidance separately because it's included in this code so what if you have a fine needle biopsy um different lesions same imaging the last one remember was same lesion same guidance so in this case you've got different lesions if both of the if you're doing different lesions in both procedures use the same in imaging guidance use the primary code for the fine needle aspiration biopsy with the type of guidance and then a code for the needle core needle biopsy with the modifier 59 that's what the guidelines state if they're deletions on the other hand use the primary code for the fna with the type of guidance use a code for the core needle biopsy with the modifier 59 and in this case you'll also code for the guidance with the modifier 59 so that's a little different so it depends on whether it's the same lesion or a different lesion here's the final practice fine needle aspiration biopsies of lesion in the right lung without guidance and coronal biopsy of the mass and the abdomen using ct guidance so and here are our questions again to kind of take us through the thought process involved was guidance used for the fine needle aspiration no was more than one biop lesion biopsies biopsy using fna so for the fine needle aspiration it was only the right lung with a fine needle aspiration core needle biopsy on the same lesion these are different lesions and this one is without guidance and this one is with ct guidance and that's what determines the code so you have fna of the right lung one zero zero two one which is the code for no guidance then you have core needle biopsy of the abdomen which is four nine one eight zero with that 59 modifier but you also have a code for the guidance 77012-59 and there's a note under 49180 saying if imaging guidance is performed c and it lists possible codes so this is an fna and core needle biopsy different lesions different modalities so these are for a small number of codes these are pretty confusing and it isn't it's very difficult to remember all the guidelines for coding this is why it's so important to make notes in your book for fine needle aspirations i would write in the questions was guidance used for fna was more than one lesion biopsy more one lesion was biopsy was the same type of guidance used with fna and core needle biopsy in the same session and if so was it the same or different lesions in the index i would write in next to the main term biopsy see also fine needle aspiration biopsy because that's not directly in there if you look up biopsy you might end up with the wrong one if you don't have that note so here's a summary of these confusing guidelines i have written these in my book on the page opposite the codes so that's what you might want to do it's all in those paragraphs that introduce this section but it's confusing so this is what i wrote in fna different lesions same modality do a primary code and it's add-on code or codes depending on how many lesions fna different lesions different modalities primary codes for each fna with modifier 59 on the second code fna plus core biopsy same lesion same modality report both codes don't report imaging separately for the core biopsy fna plus core biopsy different lesions same modality report both with modifier 59 on the core biopsy code and on the code for guidance for the core biopsy fna plus core biopsy different lesions different modalities report both using modifier 59 on the core biopsy and on the imaging for the core biopsy so that completes this lesson if you have questions or comments please feel free to contact me if you'd like um look into my books here's the books i have written and here's the covers of the books you can contact me here i'd love to hear from you here are where my contacts for my books or you can just go into amazon and type in amazon books and type in my last name tropin thank you so much for listening i hope to have more lessons up soon thank you