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ICD-10-PCS: Biopsy: With or without a
Definitive Procedure
June 25, 2015
Vol. 15
Biopsy has the following definitions:
• 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 lung
What 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
Section
Body System
Operation
0 Medical and Surgical
B Respiratory System
9 Drainage: Taking or letting out fluids and/or gases from a body part
Body Part
1 Trachea
2 Carina
3 Main Bronchus, Right
4 Upper Lobe Bronchus, Right
5 Middle Lobe Bronchus, Right
6 Lower Lobe Bronchus, Right
7 Main Bronchus, Left
8 Upper Lobe Bronchus, Left
9 Lingula Bronchus
B Lower Lobe Bronchus, Right
C Upper Lung Lobe, Right
D Middle Lung Lobe, Right
F Lower Lung Lobe, Right
Approach
0
3
4
7
8
Open
Percutaneous
Percutaneous Endoscopic
Via Natural or Artificial Opening
Via Natural or Artificial Opening Endoscopic
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Device
Z No Device
Qualifier
X Diagnostic
Z No Qualifer
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Fine needle aspiration (FNA) biopsy of middle lobe of right lung 0B9D3ZX
Biopsy of bone marrow
What does the coder need to know?
• Root operation: In the Index the term “Biopsy - Bone Marrow” gives the coder direction to use the term “Extraction” with qualifier
“Diagnostic”
• Body part: Which bone is the marrow extracted from
• Approach: Open or Percutaneous
• Qualifier: Biopsy = Diagnostic
Scenario: Needle biopsy of bone marrow of the iliac crest
Section
Body System
Operation
0 Medical and Surgical
7 Lymphatic and Hemic Systems
D Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force
Body Part
Q Bone Marrow, Sternum
R Bone Marrow, lliac
S Bone Marrow, Vertebral
Approach
0 Open
3 Percutaneous
Device
Z No Device
Qualifier
X Diagnostic
Z No Qualifer
Needle biopsy of bone marrow of the iliac crest 07DR3ZX
Lymph node sampling
What does the coder need to know?
• Root operation: In the Index the term “Biopsy” gives the coder direction to use the term “Drainage” or “Excision” with qualifier
“Diagnostic”
o
The following portion of the Guideline tell us to use the term “Excision”
•
“Lymph node sampling for biopsy is coded to the root operation Excision…”
• Body part: Which lymph node is being sampled
• Approach: Open, Percutaneous, or Percutaneous Endoscopic
• Qualifier: Biopsy = Diagnostic
Scenario: Percutaneous lymph node sampling of left axillary lymph node
Section
Body System
Operation
0 Medical and Surgical
7 Lymphatic and Hemic Systems
B Extraction: Cutting out or off, without replacement, a portion of a body part
Body Part
0 Lymphatic, Head
1 Lymphatic, Right Neck
2 Lymphatic, Left Neck
3 Lymphatic, Right Upper Extremity
4 Lymphatic, Left Upper Extremity
5 Lymphatic, Right Axillary
6 Lymphatic, Left Axillary
7 Lymphatic, Thorax
8 Lymphatic, Internal Mammary, Right
9 Lymphatic, Internal Mammary, Left
B Lymphatic, Mesenteric
C Lymphatic, Pelvis
D Lymphatic, Aortic
Approach
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
Device
Z No Device
Qualifier
X Diagnostic
Z No Qualifer
Percutaneous lymph node sampling of left axillary lymph node 07B63ZX
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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:
Partial mastectomy left breast
Left breast biopsy
• Which breast? Left
• Which breast? Left
• Root operation? Removing a portion of a
body part = Excision
• Root operation? Removing a portion of a
body part = Excision
• Approach? Percutaneous
• Approach? Open
• Qualifier? Biopsy = Diagnostic
• Qualifier? No Qualifier
“… a needle biopsy of the left breast.”
Section
Body System
Operation
0 Medical and Surgical
H Skin and Breast
B Excision: Cutting out or off, without replacement, a portion of a body part
Body Part
T Breast, Right
U Breast, Left
V Breast, Bilateral
W Nipple, Right
X Nipple, Left
Y Supernumerary Breast
Approach
0 Open
3 Percutaneous
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic
X External
Device
Z No Device
Qualifier
X Diagnostic
Z No Qualifer
“... a needle biopsy of the left breast.” 0HBU3ZX
“…an open partial mastectomy of the left breast.”
Section
Body System
Operation
0 Medical and Surgical
H Skin and Breast
B Excision: Cutting out or off, without replacement, a portion of a body part
Body Part
T Breast, Right
U Breast, Left
V Breast, Bilateral
W Nipple, Right
X Nipple, Left
Y Supernumerary Breast
Approach
0 Open
3 Percutaneous
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic
X External
Device
Z No Device
Qualifier
X Diagnostic
Z No Qualifer
“... an open partial mastectomy of the left breast.” 0HBU0ZZ
Note: The coder must be guided by documentation in the medical record of each individual case to make the correct code selections.
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