Biopsy guidance continues to baffle coders

September 2, 2010

CMS codes on radiologic guidance for needle placement is confusing and implementation varies by medical society and payer.

This issue of biopsy guidance will not go away and the confusion is still with us.

Version 15.3 of the CMS National Correct Coding Policy, Chapter 9, states in the Medically Unlikely Edits section:

CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not the number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

In the above statement, CMS allows one payment per encounter for needle placement guidance.

Medicare. To be in accordance with Medicare policy, code only one needle placement, according to the National Correct Coding Initiative (NCCI) guidelines. Also, remember this applies only to codes 76942, 77002, 77003, 77012, and 77021. Other guidance codes, such as mammographic (77032), stereotactic (77031), and catheter placement (75989) can be coded and modified with the -59 modifier as necessary for all payers.

Non-Medicare . For commercial insurance, consider applying modifier -59 or -76 if documentation supports the biopsy guidance procedures when reporting 76942, 77002, 77003, 77012, and 77021 for multiple lesions on the same encounter.

When multiple procedures are performed for different patient encounters on the same day, apply the appropriate modifier (-59) to distinguish payment for different encounters, including those involving Medicare patients.

Coding scenarios. Ultrasound-guided needle breast biopsy and stereotactic-guided needle breast biopsy: Your code for this ultrasound scenario will be 76942. Use 77031 with the -59 modifier on the stereotactic biopsy for all payers.

Two stereotactic needle breast biopsies: This concept would be 77031 and 77031 with the appropriate modifier -59, -76, -LT, or -RT (depending on carrier specifics) on the second guidance procedure code 77031.

Society instructions create confusion

CMS instructions state that billing for imaging guidance must be per encounter and not per lesion. However, society guidelines have always defined imaging guidance as per lesion or anatomical area involved, which has created confusion.

American Medical Association: Code 76942 should be per distinct lesion that requires separate needle placement (CPT Assistant, April 2005, page 16).

American College of Radiology: In describing ultrasound guidance for needle aspiration of two breast lesions (76942), ultrasonic guidance for needle placement is also reported twice because two lesions, one at the 2 o’clock position and the other at the 11 o’clock position, were treated. Note, it is the number of lesions sampled, and not the number of punctures, that is the determining factor on how many codes to report (Clinical Examples in Radiology, Fall 2008, page 3).

The Society of Interventional Radiology: The 2009 Coding Guidebook does not provide an opinion for how to code. “CMS has enacted MUEs (Medically Unlikely Edits), which limit the reporting of needle placement imaging guidance codes to once per session. The ACR and SIR are currently reviewing this issue as the code descriptors for the imaging guidance codes clearly state ‘biopsy’ not ‘biopsies.’ We will be exploring these edits with CMS to determine if they are appropriate or if the allowed MUE frequency unit should be increased,” it states.

This creates a bit of confusion, for now, as we must adhere to the CMS guideline and bill all of the listed imaging guidance codes only once per encounter for Medicare patients. If the specialty societies are successful in convincing CMS to increase the MUE unit frequency, then the coding can be revised.

As a reminder, charges that are denied for units in excess of the MUEs may not be billed to the beneficiary. The Advance Beneficiary Notice of Noncoverage (ABN) form cannot be used to seek payment from the beneficiary.
 

References:

American Medical Society
American College of Radiology
The Society of Interventional Radiology
Version 15.3 of the CMS National Correct Coding Policy, Chapter 9


Ms. Snyder is a certified professional coder and corporate director of coding for Zotec Partners.