Breast coding update - Understand surgical breast procedures to assign correct CPT codes

Hi to all… I thought it was fitting that I bring back an old article that I wrote in 2006, but updated with the new codes… A lot of good info here, and still as timely today, as it was then… Enjoy

Understand surgical breast procedures to assign correct CPT codes

Coders should understand medical terminology regarding surgical breast procedures to correctly bill the operative procedure that the physician performs. CPT has a complete section devoted to the breast. In this section, it is broken down into the following five core areas:

• Incision – Surgical opening made with an instrument such as a scalpel or knife -
• Excision – The surgical act of cutting out, cutting away or taking out
• Introduction – Directing or placing of a needle, catheter or other medical implement into the body
• Repair/reconstruction – To surgically correct a defect back to its original state
• Unlisted procedures – No current CPT code given to a specific procedure that the physician as documented.

Understand incision breast codes

Report the following codes for incision procedures:

• 19000—Puncture aspiration of cyst of breast –

Explanation: A direct access (through the skin) to a cyst or lump within the breast is performed with a needle or trocar, then the fluid or tissue is removed and sent to pathology for analysis. Some clinicians refer to this as a percutaneous breast aspiration. These are most often performed in the office setting.

• +19001—Add on code for each additional cyst (listed separately)

Explanation: A CPT code that is “added on” to the core code but cannot have a 51 modifier attached.

• 19020—Mastotomy w/exploration OR drainage of abscess deep –

Explanation: a surgical opening of the breast with a scalpel or knife so the physician can look around (or explore) the interior of the breast tissue. This code can also be used if the physician surgically opens the breast (incision) to drain a cyst or abscess. This procedure can be performed in the office, but many physicians prefer to do them in a surgical suite, or outpatient setting.

• 19030—Injection procedure for ductogram or galactogram

Explanation: A Physician or technician injects with a needle, contrast dye directly into the breast to image the breast ducts. These diagnostic tests are usually performed for a diagnosis of abnormal nipple discharge.

Understand excision breast codes

Report the following codes for excision procedures:

• 19100—Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)

Explanation: A biopsy the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion”. X-ray or ultrasound guidance is not used. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

• 19101—Biopsy of breast; open, incisional

Explanation: An incision is made in the breast near the site of the mass or lump. The mass or lump is identified and a small tissue specimen is removed. This specimen is examined immediately. If the mass or lump is benign, the wound is repaired with layered closure. If malignant, the incision may be closed pending a separate, more extensive surgical session.

• 19102—Biopsy of breast; percutaneous, needle core, using imaging guidance

Explanation: A biopsy of the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion”. X-ray or ultrasound guidance IS USED. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

• 19103—Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance

Explanation: A biopsy of the breast, using a long needle, through the skin, aimed toward the “lump” or “lesion” that utilizes vacuum assistance, and rotates. X-ray, fluoroscopy or ultrasound guidance IS USED. A core of breast tissue is then removed and forwarded to pathology for diagnosis.

Add on code :+ 19295—Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure)

Explanation: An actual metal clip or wire is placed within the breast, and used to delineate the area of the breast that the physician needs to biopsy or perform an open exploration.

• 19105—Ablation, cryosurgical, of fibroadenoma, including ultrasound guideance, EACH fibroadenoma

Explanation: The physician uses cryotherapy to obliterate a fibroadenoma of the breast. The patient's skin is cleansed and the ablation site is anesthetized. Ultrasound is used to locate the tumor. A cryoprobe is inserted through a small incision and placed within the fibroadenoma under ultrasound. The device initiates ice ball formation. The cryoprobe is warmed before removal from the breast. This code reports treatment of one fibroadenoma.

Radiology codes to consider with codes 19100–19103 include 76095, 76096, 76360, 76393 and 76942.

Understand FNAs

Fine needle aspiration (FNA) is a percutaneous procedure that uses a fine gauge needle (22 or 25 gauge) and a syringe to extract sample fluid from a cyst or to remove clusters of cells from a solid mass. FNA is an integral part of the diagnosis and treatment for many minor breast symptoms. Physicians use it as a tool for the diagnosis of cancerous cells within the breast.

When a physician finds a lump in the breast, he or she will send the patient to have a mammogram or ultrasound of the breast (specialized x-rays of the breasts). Depending on what the diagnostic mammogram/ultrasound reveals, the physician will determine the next course of treatment. Many times, that treatment includes a FNA in the office to determine whether the lump is solid or cystic (fluid-filled). If the FNA does not reveal any diagnostic information, the physician may consider a breast biopsy.

FNA, incisional breast procedure codes, and excisional breast procedure codes are billable for both male and female patients are not age exclusive. However, some local insurance carriers may render a “gender” denial because they view these codes are female-only. However, in men, breast lumps/cancers account for fewer than 1% of all breast malignancies reported, and 80% of all breast lumps found are benign—not malignant—according to the Y-ME National Breast Cancer Organization.^©

Report the following codes to indicate a fine-needle aspiration:

• 10021—Fine needle aspiration; without imaging guidance
• 10022—Fine needle aspiration; with imaging guidance

Explanation: Fine needle aspiration (FNA) is a percutaneous procedure that uses a fine gauge needle (22 or 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. First, the skin is cleansed. If a lump can be felt, the radiologist or surgeon guides a needle into the area by palpating the lump. If the lump is non-palpable, the FNA procedure is performed under image guidance using fluoroscopy, ultrasound, or computed tomography (CT), with the patient positioned according to the area of concern. In fluoroscopic guidance, intermittent fluoroscopy guides the advancement of the needle. Ultrasonography-guided aspiration biopsy involves inserting an aspiration catheter needle device through the accessory channel port of the echoendoscope; the needle is placed into the area to be sampled under endoscopic ultrasonographic guidance. After the needle is placed into the region of the lesion, a vacuum is created and multiple in and out needle motions are performed. Several needle insertions are usually required to ensure that an adequate tissue sample is taken. CT image guidance allows computer-assisted targeting of the area to be sampled. At the completion of the procedure, the needle is withdrawn and a small bandage is placed over the area. Report 10021 if fine needle aspiration is performed without imaging guidance. Report 10022 if imaging guidance is used to assist in locating the lump.

OB lacerations - New rules from ACOG & Placenta delivery only's

Well... just when you think you've got the world by the tail... someone changes the rules, and the world whirls around and bites you!!!

with this said... I was working on an appeal for payment of a 3rd degree laceration code that was performed at the time of a delivery. However...... in my research I found out that ACOG (American Congress of Obstetricians & Gynecologists) has bundled 3rd and 4th degree lacerations into the regular delivery code, but you are to append the modifier 22. (Effective as of Jan 1 2010)

My suggestions for getting this paid with the mod 22 attached is to ensure that the documentation from the provider states that the laceration is a 3rd or 4th degree, and clearly states the repair. If possible, have the provider also document the time it took to do this repair, over and above a 1st or 2nd degree repair. (which is also bundled into the delivery, but not separately payable).

So - If you are having the headache of not getting paid for those pesky lacerations.. ACOG put this out in their 2010 ACOG coding manual. If you need or want more info regarding this, please let me know or contact the ACOG for more info. As we all say... we learn more from our mistakes and failures, than we do from our successes. This was a great learning experience for me, so I'm glad to share with you!

Also... I had a situation come up this week, where the OB hospitalist arrived as the baby was being delivered by the nursing staff... and we debated whether or not to bill for a "precipitous delivery" or a "placenta delivery" only.

After much debate, we decided upon the "placenta delivery" only. That way, the OB hospitalists could get paid for the work they performed, and the antepartum care and the postpartum care would be billed by the OB that provided that service.

So what I learned from this last week... is you just never quit learning!!! PS... new ICD-9 codes were effective as of 10.01.2010... so be sure to review the new codes and put them into practice.

... Happy Coding.......... L : )

Coding/Billing Guidelines for “Family visits/Consultations”

Coding/Billing Guidelines for “Family visits/Consultations”

This came to me this week when a co-worker’s family wanted to meet with the physician regarding a plan of care for dealing with her elderly parents, and their medical, social, and basic living needs. She was shocked to find out they could not just “bill” her Mom’s medicare. So, after some discussion and research this is what I found out we can do. (as a Coder, Provider or family member)

The bottom line from all the research that I did…. is that 3^rd party payors do not want to pay for medical counseling unless the benificiary is present when the provider renders this service.

When I started digging, (and numerous phone calls made) the rationale from insurance carriers…to put in layman’s terms; it’s the same as “stolen identity”. Ie… "your credit card has been stolen and is being used to purchase services the cardholder never received or authorized". This made total sense to me once explained . (I also hadn't thought about the HIPPA issues involved too)

Wow!!!!… I guess I never realized that this could be such an complex issue for coders and providers too. CMS and CPT both have rules the providers must follow but do not necessarily mirror each other especially in light of HIPPA, billing criteria, and how to code for these services.

Anyway………Here’s the info I found to share on the subject for coders, providers, medical offices and family members to ponder if you are presented with this situation… I hope this clarifies some of the issues that surround this sticky issue! and as always, feel free to contact me regarding ??'s at webbservices.lori@gmail.com.

Enjoy! L : )

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CPT gives us some direction how to deal with this…(straight from CPT)

99201 (-02, -03, -04, -05) Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family

So, in CPT language, this can be interpreted as

§ The provider can provide care and/or counseling and coordination of care with just the patient

§ The provider can provide care and/or counseling and coordination of care with just the family member

§ The provider can provide care and/or counseling and coordination of care with both together.

Where this gets problematic is the billing issues. These issues encompass the place of service such as Hospital, (Inpatient & Outpatient) Office and Emergency Room…So let’s clarify what we need to do:

Medicare/Medicaid for Office/Outpatient Services:

For Office/Outpatient services, CMS does not allow for payment unless the patient is present at the time the services are rendered. The rationale behind this is Medicare considers this part of the pre-post workup for an E&M service, and is a long standing Medicare Policy.

An ABN cannot be used as the patient was not there and engaged in the face-to face process. rationale: the ABN has to be acknowledged and signed by the beneficiary, which cannot be done if the patient is not in attendance.

Private Payor for Office/Outpatient Services

Again, we can default back to the CPT guidelines, but many private payors have contractual or internal policies regarding this type of service. CPT states we can use the code, but it will be up to the private payor to determine if they will pay for the service. If you plan to bill a private payor for “family counseling” here are a couple of options you can consider:

§ Bill the patient’s carrier with a paper claim, utilizing the standard E&M codes; submit the claim with documentation stating medical necessity of meeting with the family, without the patient present, be sure to use the diagnosis “V” code of V65.19: "Other person consulting on behalf of another person." (i.e. full disclosure of the nature of the visit to the carrier)

§ Schedule an appointment with the family member, as a patient in your practice, and bill his/her insurance payer for counseling coordination of care of themselves in relation to their family members medical issues (such as the stress on you as a care-giver, etcc)

§ Schedule an appointment with the provider for the family member(s) and inform the family members that for xxx amount of time, the charge is $XXX.oo. Disclose to the family members that this will need to be paid in full up front, at the time of visit. You also need to inform the family at the time of scheduling that without the patient’s consent, (or medical power of attorney) the provider/physician may not be able to disclose any information regarding the patient due to HIPPA privacy laws.

Inpatient services:

In regard to the Inpatient side of things, it works just a bit differently. The patient is currently present in the hospital, so this is much easier for the physician to communicate and coordinate care in regard to the patient with the family members. The argument of the patient not being there is irrelevant.

In some cases the patient is so critically ill, that a family member can “speak for” the patient in regard to history, and social issues if the patient cannot speak for themselves, and may have the ability to made medical decision based on a medical power of attorney, living will, or current care-giver or spousal status.

CPT is very specific in regard to code selection for admission and subsequent visits in regard to counseling/coordination of care. 50% (or more) of the time spent. must be documented as counseling and/or coordination of care to bill by time default. Otherwise the guidelines of history, exam and medical decision making must be followed. As the coder you need to carefully read the guidelines set for by CPT in the CPT manual.