Sample biopsy coding for accuracy

Inpatient biopsy procedures can bring in big dollars, but they also carry significant audit risks. In 2012, Recovery Auditors (RAs) identified more than $11 million in improper payments for closed biopsies of the lung. The RAs found that facilities billed for transbronchial lung biopsies when the physicians actually performed a transbronchial biopsy.

 

During a biopsy, a physician removes a small tissue sample for closer examination, says Mark N. Dominesey, MBA, RN, CCDS, CDIP, director of auditing and clinical documentation improvement services for TrustHCS in Springfield, Mo.

 

Physicians can biopsy numerous body sites and structures, including muscles, organs, and bodily fluids. Coders should be able to tell from the operative report whether the physician biopsied a tissue sample or a fluid, Dominesey says. Physicians often use biopsies to look for cancer, but they can perform biopsies for other reasons.

 

Most coders are familiar with a breast biopsy performed to detect breast cancer or a skin biopsy used to identify malignant skin lesions. Physicians may also perform a liver biopsy in a patient with chronic hepatitis to determine whether the patient also has cirrhosis.

 

Physicians may also biopsy normal-looking tissue to determine whether a patient’s cancer has spread or to make sure a patient is not rejecting an organ or tissue transplant.

 

Physicians can use a variety of methods to obtain a biopsy. For example, the physician can perform a liver biopsy using fine needle aspiration (ICD-9-CM procedure code 50.11). The physician inserts a thin, hollow needle into the mass to collect a sample of cells. This is a percutaneous procedure. The physician may use CT or ultrasound guidance to ensure correct placement of the needle.

 

The physician may also elect to perform an open biopsy of the liver (ICD-9-CM procedure code 50.12). An open biopsy is an operation performed under local or general anesthesia. The surgeon makes a cut into the affected area and removes the tissue.

 

The ICD-9-CM procedure codes include specific codes to report biopsies. Coders can look up the term biopsy and see all of the corresponding body areas.

 

The codes are divided by the site of the biopsy. Biopsies of the bladder are reported using codes in the urinary procedure codes, while a brain biopsy is coded to the nervous system procedures. For example, if a physician performs a biopsy of the abdominal wall, coders would report ICD-9-CM procedure code 54.22 (biopsy of abdominal wall).

 

 

Biopsies are further divided by the type of biopsy. In ICD-9-CM procedure coding, coders can choose between the following codes for a lung biopsy:

 

Code 33.24 includes brush biopsy of lung, brushing or washing for specimen collection, excision (bite) biopsy, and diagnostic bronchoalveolar lavage.

 

Code 33.26 includes fine needle aspiration and transthoracic needle biopsy of the lung.

 

Code 33.27 is reported for fiber-optic (flexible) bronchoscopy with fluoroscopic guidance with biopsy and transbronchial lung biopsy.

 

The Medical/Surgical section of the ICD-10-PCS Manual includes 31 root operations. Biopsy is not one of them. When coders look up the term biopsy in the ICD-10-PCS Manual, they are instructed to:

 

In ICD-10-PCS, coders select the root operation based on the intent of the procedure. The physician performs a fine needle aspiration biopsy of the liver. Because the physician is removing some tissue to be sent to pathology, coders would use root operation excision (cutting out or off without replacement a portion of a body part), says Dominesey. 

 

Coders also need to know that the seventh character—the qualifier—would be X for diagnostic, says Nena Scott, MSEd, RHIA, CCS, CCS-P, and AHIMA-approved ICD-10-CM/PCS trainer, director of education at TrustHCS.

 

ICD-10-PCS includes three separate body part values for the liver:

 

If the physician performed a fine needle aspiration biopsy of the right lobe of the liver, coders would report 0FB13ZX (excision of right lobe liver, percutaneous approach, diagnostic).

 

If the physician uses an open approach but does not specify which lobe was biopsied, coders would report 0FB00ZX (excision of liver, open approach, diagnostic).

 

If the physician cuts through the patient’s skin and intervening tissue to expose the liver and uses a needle to take the sample, use the character for an open approach. If the physician inserts a needle through the skin and intervening tissue to obtain the biopsy, report the approach as percutaneous.

 

In some cases, the physician may be taking a fluid sample to biopsy. When the physician removes a fluid for biopsy, coders will use root operation drainage (taking or letting out fluids and/or gases from a body part).

 

For example, a physician decides to biopsy fluid from the patient’s lung. Coders would go to ICD-10-PCS table 09B (respiratory system drainage). Then they need to determine the body part value based on the physician’s documentation. ICD-10-PCS table 09B includes options for:

 

 

If the physician does not specify the lobe of the lung, coders can chose right lung (K), left lung (L), or bilateral lung (M). Without the laterality, coders cannot select a code.

 

Coders also need to carefully read the operative report to determine whether the fluid was taken from the lung itself or from the pleura. ICD-10-PCS includes body part values for:

 

Coders also need to know the approach in order to assign the fifth character. For lung drainage, the approaches include:

For the pleura, coders can only choose open, percutaneous, and percutaneous endoscopic approaches

 

The device is always Z (no device). Only devices that remain in the patient are coded in ICD-10-PCS, Scott says. Because the procedure is a biopsy, the seventh character is X (diagnostic).

 

Bone marrow biopsies are reported using root operation extraction and the diagnostic qualifier. ICD-10-PCS includes three body parts for bone marrow extraction:

The approach is either open or percutaneous and the qualifier is X.

 

In some cases, a physician may perform a biopsy and an additional procedure in the same body system. For example, the physician may perform a destruction of a sigmoid lesion and a biopsy of a sigmoid colon. Those procedures would be coded separately, says Scott, because the intent of the procedures is different. 

 

However, procedures that are integral to the biopsy are not coded separately, Scott says. If a physician performs a laparotomy to reach the site of an open liver biopsy, coders only report the biopsy.