April 2, 2007

Coding for Biopsy
For The Record
Vol. 19 No. 7 P. 31

A biopsy is a procedure during which a sample of tissue is removed from a patient and examined under a microscope to aid in an accurate diagnosis. Before assigning a code for the procedure, the coder should read the entire operative note to verify the procedure performed. Sometimes the physician uses the term biopsy when a biopsy was not performed. If the physician documents excisional biopsy but removes an entire lesion, assign the code for the lesion excision. When only a portion of the lesion is excised, the biopsy code is assigned (AHA Coding Clinic for ICD-9-CM, 1990, second quarter, page 28).

Open vs. Closed Biopsy
Biopsies are typically classified as open or closed. A closed biopsy is performed by one of the following:

• aspiration;

• brush (tissue is removed by using a brush or bristle to collect cells for cytological exam);

• endoscopy (biopsy through a flexible tube inserted into an orifice [such as the mouth or anus] or through a small skin incision);

• needle (small sample of lump removed through a slender hypodermic needle);

• percutaneous; and

• stereotactic (provides accurate needle placement using 3-D coordinate guidance for directing the needle used during a biopsy. Assign code 93.59 along with the biopsy code to identify the technique used [AHA Coding Clinic for ICD-9-CM, 1994, fifth issue, page 8]).

The ICD-9-CM index has been significantly updated under the main term biopsy to include the endoscopic approach. However, if a biopsy was performed through an endoscope and the index does not provide a code for the endoscopic biopsy, then a code for both the endoscopic approach and the biopsy is assigned. Sequence the endoscopy code first. For example, a biopsy of the urethra performed via cystourethroscopy is assigned to codes 57.32 and 58.23 (Faye Brown’s ICD-9-CM Coding Handbook, American Hospital Association, 2004 Revised Edition, page 52).
An open biopsy is the removal of tissue by way of an incision. The incision is inherent to an open biopsy, so an additional code for the incision is unnecessary. Occasionally, a biopsy is performed along with a more definitive procedure. A code for both the biopsy and definitive procedure is assigned with the code for the definitive procedure sequenced first. For example, a resection of the ascending colon is performed due to malignancy of the colon. The surgeon also performs a liver biopsy during the procedure to determine whether the cancer has spread. Assign codes 45.73 and 50.12. However, if the biopsy was performed via a needle, the code for the closed biopsy would be assigned. The technique used to obtain the tissue determines the biopsy code assigned. Therefore, in the above example, if the liver biopsy was performed by a needle after the right hemicolectomy, code 50.11 would have been assigned instead of code 50.12. Another example is an exploratory laparotomy with needle biopsy of the pancreas, which is assigned to codes 54.11 and 52.11.

Occasionally, the surgeon will perform a frozen section during the surgery. This involves the surgeon taking a section of frozen tissue from the patient and examining it within a few minutes during the operation. Therefore, the surgeon can immediately modify the extent of the surgery as necessary. In this case, it is appropriate to assign a code for the biopsy along with the therapeutic procedure performed with the therapeutic code sequenced first.

Thoracoscopy
Thoracoscopic wedge biopsy of the lung is classified to code 33.28, Open biopsy of lung. Thoracoscopic wedge resection of the lung is assigned to code 32.29, Local excision or destruction of lesion of lung. The coder should be guided by the physician’s documentation and the procedure performed.

In ICD-9-CM, surgical approaches (eg, scopes) are not coded if a more definitive procedure is performed. Therefore, if a procedure was done via scope, assign a code for the procedure (open) performed, but do not assign a separate code for the scope (AHA Coding Clinic for ICD-9-CM, 1992, third quarter, pages 12-13 and 1992, first quarter, page 12). However, if a diagnostic exploratory procedure is performed along with the biopsy, both the biopsy and exploratory procedure codes are assigned. For example, exploratory thoracoscopy and a pleural biopsy are assigned to codes 34.21 and 34.24. The surgeon states that the thoracoscopy involved more than the operative approach, and Coding Clinic advises to code both procedures (AHA Coding Clinic for ICD-9-CM, 2002, third quarter, page 27).

Coding and sequencing for biopsy are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.