By Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer
Biopsies are performed, most often, for diagnostic purposes. These procedures are done to obtain a sampling of cells or piece of tissue from the body that can then be pathologically analyzed. In ICD-10-PCS, a biopsy is not a biopsy.
Actually, there is no “biopsy” term available in this code set. ICD-10-PCS uses a variety of terms to describe these procedures, determined by what is actually done by the physician as explained by the Official Guidelines for Coding and Reporting 2016 guideline B3.4a: “Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic.”
Fine-needle aspiration biopsy is reported with the root operative termDrainage (taking or letting out fluids and/or gases from a body part) in ICD-10-PCS. When you think about it, this is actually more specific and accurate, as the physician uses a thin needle to draw out–or drain–some fluid or gas to be used for testing.
For example, an amniocentesis would be reported with ICD-10-PCS code 10903ZU (Drainage of amniotic fluid, diagnostic from products of conception, percutaneous approach). Each of the characters making up the code would be:
- 1, obstetrics
- 0, pregnancy
- 9, Drainage
- 0, products of conception
- 3, percutaneous approach
- Z, no device
- U, amniotic fluid, diagnostic
A lumbar puncture (spinal tap) would be reported with code 009Y3ZX (Drainage of lumbar spinal cord, percutaneous approach, diagnostic). Each character would be:
- 0, medical and surgical section
- 0, central nervous system
- 9, Drainage
- Y, lumbar spinal cord
- 3, percutaneous approach
- Z, no device
- X, diagnostic
Core needle biopsy is reported with root operation Extraction (pulling or stripping out or off all or a portion of a body part by the use of force) because the physician uses a hollow needle, a bit larger than the needle used during a fine needle biopsy, to extract a cylindrical section of tissue to be analyzed.
For example for a bone marrow biopsy, the correct ICD-10-PCS code could be 07DR3ZX (Extraction of iliac bone marrow, percutaneous approach, diagnostic). The individual characters would be:
- 0, medical and surgical section
- 7, lymphatic and hemic system
- D, Extraction
- R, bone marrow, iliac, but it could also be Q for bone marrow, sternum, or S for bone marrow, vertebral
- 3, percutaneous approach, though it could also be 0 for an open approach
- Z, no device
- X, diagnostic
A punch biopsy of the skin could be reported with code 0JDD3ZX (Extraction of right upper arm subcutaneous tissue and fascia, percutaneous approach). The individual characters would be:
- 0, medical and surgical section
- J, subcutaneous tissue and fascia
- D, Extraction
- D, subcutaneous tissue and fascia, upper arm or various other characters for other specific anatomical sites
- 3, percutaneous approach or potentially reported with 0 for Open
- Z, no device
- Z, diagnostic
Excisional and incisional biopsies are reported as an Excision (cutting out or off, without replacement, a portion of a body part), whether a sampling of tissue or an entire tumor or abnormal area is taken during the procedure.
For example, a liver biopsy could be reported with code 0FB20ZX (Excision of left lobe liver, open approach, diagnostic). The individual characters are:
- 0, medical and surgical section
- F, hepatobiliary system and pancreas
- B, Excision
- 2, liver, left lobe
- 0, open or 3 for percutaneous approach or 4 for percutaneous endoscopic
- Z, no device
- X, diagnostic
A scrotum biopsy would be reported with 0VB5XZX (Excision of scrotum, external approach, diagnostic). The characters are:
- 0, medical and surgical section
- V, male reproductive system
- B, Excision
- 5, scrotum
- X, external
- Z, no device
- X, diagnostic
Endoscopic biopsyis reported with the same root operation, Excision, however, coders will explain this circumstance with the appropriate approach–the fifth character: percutaneous endoscopic (4) or via natural or artificial opening endoscopic (8).
A natural or artificial opening endoscopic is defined as entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure.
For example, a cystoscopy with biopsy would be reported with 0TBB8ZX (Excision of bladder, via natural or artificial opening endoscopic, diagnostic), depending on approach. The individual characters are:
- 0, medical and surgical section
- T, urinary system
- B, Excision
- B, bladder
- 8, via natural or artificial opening endoscopic
- Z, no device
- X, diagnostic
A stomach biopsy is reported with 0DB68ZX (Excision of stomach, via natural or artificial opening endoscopic, diagnostic), depending on approach. The individual characters are:
- 0, medical and surgical section
- D, gastrointestinal system
- B, Excision
- 6, stomach
- 8, via natural or artificial opening endoscopic
- Z, no device
- X, diagnostic
At times, the biopsy may be done and analyzed and directly followed by a more extensive procedure during the same encounter or session. The Official Guidelines for Coding and Reporting 2016 explain in section B3.4b that both should be reported (separately).
For example, a physician performs a lumpectomy of the right breast followed by mastectomy during the same session. Coders should report codes 0HBT3ZX (Excision of right breast, percutaneous approach, diagnostic) and 0HTT0ZZ (Resection of right breast, open approach). The individual characters for these respective codes are:
- 0, medical and surgical section
- H, skin and breast
- B, Excision
- T, breast, right
- 3, percutaneous
- Z, no device
- X, diagnostic
And:
- 0, medical and surgical section
- H, skin and breast
- T, Resection
- T, breast, right
- 0, open
- Z, no device
- Z, no qualifier
Editor’s note: Safian, of Safian Communications Services in Orlando, Florida, is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at [email protected].