This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
ICD-10-PCS: Biopsy: With or without a Definitive Procedure
• The removal of a small piece of tissue for laboratory examination
• A sample of tissue taken from the body in order to examine it more closely
• A procedure to remove a piece of tissue or a sample of cells from your body so that it can be analyzed in a laboratory
• The removal of cells or tissues for examination by a pathologist
When coding biopsies it is important not only to know what a biopsy is, but also how they may be performed.
Types of biopsy:
• Needle biopsy which will code to approach “Percutaneous”
o Fine Needle Aspiration Biopsy (FNAB): A very thin needle is attached to a syringe to aspirate a small amount of tissue from a suspicious area
o Core Needle Biopsy (CNB): A slightly larger, hollow needle is used to withdraw small cylinders (or cores) of tissue from the abnormal area
o Stereotactic core needle biopsy: Uses x-ray equipment and a computer to analyze pictures of the organ with the abnormality; the computer then pinpoints exactly where in the abnormal area the needle tip needs to go
• Open biopsy which will code to approach “Open”
o A procedure in which a surgical incision is made through the skin to expose and remove tissues
• Closed biopsy which will code to approach “Via natural or artificial opening” or “Via natural or artificial opening endoscopic”
o Involves a much smaller incision than open biopsy. The small incision is made to allow insertion of a visualization device, which can help guide the physician to the right place to take the sample.
The ICD-10-PCS Guidelines give direction on the coding of biopsies.
ICD-10-PCS Official Guidelines for Coding and Reporting 2015 Biopsy procedures B3.4a Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. The qualifier
Diagnostic is used only for biopsies. Examples: Fine needle aspiration biopsy of lung is coded to the root operation Drainage with the qualifier Diagnostic. Biopsy of bone
marrow is coded to the root operation Extraction with the qualifier Diagnostic. Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic.
Let’s code each of the examples given in the above Guideline.
Fine Needle Aspiration (FNA) biopsy of lungWhat does the coder need to know?
• Root Operation: In the Index the term “Aspiration” gives the coder direction to use the term “Drainage”
• Body Part: Lung requires knowledge of laterality and lobe
• Approach: FNA = Percutaneous
• Qualifier: Biopsy = Diagnostic
Scenario: Fine Needle Aspiration (FNA) biopsy of middle lobe of right lung
Vol. 15
SectionBody SystemOperation
Medical and SurgicalRespiratory SystemDrainage: Taking or letting out fluids and/or gases from a body part
0B9
0 Open3 Percutaneous4 Percutaneous Endoscopic7 Via Natural or Artificial Opening8 Via Natural or Artificial Opening Endoscopic
The ICD-10-PCS Guidelines also give direction on the coding of biopsies accompanied by a definitive procedure.
ICD-10-PCS Official Guidelines for Coding and Reporting 2015 Biopsy followed by more definitive treatment B3.4b If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction,
Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded. Example: Biopsy of breast followed by partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy
procedure are coded.
Let’s code an example based on the above Guideline.
Scenario: Patient presents with a suspicious lump in her left breast. The physician performs a needle biopsy of the left breast. Based on the results the physician proceeded with an open partial mastectomy of the left breast.
What does the coder need to know? There are two procedures to be coded:
“… a needle biopsy of the left breast.”
June 09, 2015Vol. 15
Left breast biopsy • Which breast? Left
• Root operation? Removing a portion of a body part = Excision
• Approach? Percutaneous
• Qualifier? Biopsy = Diagnostic
Partial mastectomy left breast • Which breast? Left
• Root operation? Removing a portion of a body part = Excision
• Approach? Open
• Qualifier? No Qualifier
SectionBody SystemOperation
Medical and SurgicalSkin and BreastExcision: Cutting out or off, without replacement, a portion of a body part
0HB
0 Open3 Percutaneous7 Via Natural or Artificial Opening8 Via Natural or Artificial Opening EndoscopicX External
X DiagnosticZ No Qualifer
Z No DeviceT Breast, RightU Breast, LeftV Breast, BilateralW Nipple, RightX Nipple, LeftY Supernumerary Breast
Body Part Approach Device Qualifier
“... a needle biopsy of the left breast.” 0HBU3ZX
“…an open partial mastectomy of the left breast.”
SectionBody SystemOperation
Medical and SurgicalSkin and BreastExcision: Cutting out or off, without replacement, a portion of a body part
0HB
0 Open3 Percutaneous7 Via Natural or Artificial Opening8 Via Natural or Artificial Opening EndoscopicX External
X DiagnosticZ No Qualifer
Z No DeviceT Breast, RightU Breast, LeftV Breast, BilateralW Nipple, RightX Nipple, LeftY Supernumerary Breast
Body Part Approach Device Qualifier
Note: The coder must be guided by documentation in the medical record of each individual case to make the correct code selections.
“... an open partial mastectomy of the left breast.” 0HBU0ZZ