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Reporting biopsies with ICD-10-PCS

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].
 

HCPro.com – JustCoding News: Inpatient

Dilations and Biopsies during EGD

My physicians will very seldom require to use an alternate method of dilation when one doesn’t produce the result they desire. For example, they will perform a 43248(guide wire) and a 43249(balloon) in the same session. Most recently, we billed those two codes along with a 43239(biopsy) and received a denial only for the biopsy. Both dilations were allowed and paid. Is anyone aware of a new CCI edit or otherwise restricting these code parings? If we were to bill only one dilation with the biopsy we would be paid substantially more then the payments received for both dilations which makes no sense. Thoughts appreciated.

Medical Billing and Coding Forum

TURBT with ureteral biopsies

Looking for some advice on the following:

OPERATION: Cystoscopy, transurethral resection of bladder tumor,
right diagnostic ureteroscopy with biopsies of right distal ureter,
right retrograde pyelogram, and right ureteral stent change.

DESCRIPTION OF OPERATION:
The patient was identified in the waiting area and brought into the
room. Preoperative antibiotics consisting of Levaquin and
gentamicin were provided, and general anesthesia administered. The
patient was placed in lithotomy position, then prepped and draped in
a standard sterile surgical fashion. Time-out was performed.
Consent and laterality were verified. Cystoscopy was performed
using a 30-degree scope. No strictures in the anterior urethra.
Open prostatic fossa consistent with prior BPH surgery. The bladder
was entered. The patient had extensive grade 3 or 4 trabeculation
throughout the bladder along with diverticula in the posterior
aspect of the bladder. The stent was noted emanating from the right
ureteral orifice. Just above and lateral to the right ureteral
orifice, the patient had extensive inflammation with the medial part
of that inflammation suspicious for bladder cancer. This appears to
be the site of prior TURBT. At this point, I inserted a 26-French
resectoscope, and using sterile water with continuous irrigation, I
went ahead and resected the mass, which was extending close to the
right ureteral orifice along with the inflammation lateral to it.
This measured approximately 2.5 cm in total.
The resection base was
cauterized. Next, the patient also was noted to have inflammation
extending more laterally. I did take a quick resection of that and
sent it for specimen to confirm this is not tumor. After confirming
there was no bleeding from the resection site and all the mass
fragments were evacuated using the Ellik evacuator, I reinserted the
22-French cystoscope and pulled the stent out of the urethral
meatus.
A Sensor wire was then passed through the stent into the
right kidney. I then assembled a short rigid ureteroscope and
advanced it through the right ureteral orifice.
I then performed a
retrograde study through the scope
revealing a filling defect at the
area of the UVJ and concentric filling defects approximately 3 cm
proximal to the UVJ. I then inserted the ureteroscope through the
right ureteral orifice and inspected the ureter carefully.
The
patient had inflammation at the area of the UVJ proximal to it and
some inflammatory protrusions about an inch from the UVJ. Proximal
to that, I inserted the scope and the mucosa appeared smooth without
any defect. I was able to pass the ureteroscope easily to the mid
ureter above the pelvic inlet. Retrograde revealed some
hydronephrosis without filling defect in the mid and proximal
ureter, and no obvious filling defects in the collecting system.
Next, a flexible biopsy cup was introduced through the ureteroscope
and 4 separate biopsies were performed from the UVJ inflammation
area as well as the concentric inflammation proximal to it.
The
specimens were small and were handed to pathology for quick
processing. Reinspection revealed no active bleeding. I removed
the ureteroscope and using fluoroscopic guidance and cystoscopy,
placed a 6 x 26 stent over the wire. The stent was noted to coil
nicely in the kidney and in the bladder.
Again inspection of the
bladder revealed no bleeding. A 20-French Foley catheter was
inserted and balloon inflated with 10 mL of sterile water. The
patient tolerated the procedure well.

I’ve come up with 52235 for the TURBT, 52354 for the ureteral biopsy, 52332 for stent change, and 74420-26 for the pyelogram. However, my encoder indicates that 52332 bundles into 52235 and 52235 itself bundles into 52354 (but 52332 does NOT bundle into 52354). Are any modifiers warranted here or should I just be billing 52354 & 74420-26? Any help would be appreciated. Thanks.

Medical Billing and Coding Forum