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In vascular surgery, the question of how to code an abdominal aortogram is the topic of many emails I have received over my career and a question I see posted on forums online pretty regularly. So I wanted to dedicate today’s article to answering the question of whether to code CPT 75630 or 75625 when coding a report describing an abdominal aortogram. Distinguishing these codes becomes particularly challenging when imaging of some or all of the arteries of the legs (a lower extremity angiogram) is performed in conjunction with the aortogram. Before we dive into some guidelines and examples, here are a few terms you need to be familiar with to help you understand reports for this procedure:

• Aorta: The aorta is largest artery in the body. This artery extends from the heart to the iliac arteries in the pelvis. The aorta is divided into four segments in anatomy. I have explained the definition and location of all four segments below, but today, we will be focused on the abdominal aorta.
• Abdominal aorta: The segment of the aorta which begins at the level of the diaphragm (the muscle that separates your chest cavity from your abdomen) and continues to what is known as the aortic bifurcation where the abdominal aorta branches into the right and left common iliac arteries which supply blood flow to your legs. This is the segment of the aorta we will be discussing today.
• Descending thoracic aorta: The segment of the aorta which begins at the lower end of the aortic arch (explained below) and proceeds down to the level of the diaphragm.
• Aortic arch: The segment of the aorta which is located between the ascending aorta and the descending thoracic aorta and is the portion of the aorta where the “head vessels” (the subclavian, the carotid, and the brachiocephalic trunk arteries which supply blood flow to the head, neck, and arms) branch off.
• Ascending Aorta: The segment of the aorta that begins at the upper end of the aortic arch and continues through the aortic root and down to the aortic valve.  The aortic root is where the coronary arteries which supply blood flow to your heart connect to the aorta.  The aorta ends at this point (the heart is located on the other side of the aortic valve).
• Aortogram: A set of images obtained in one segment of the aorta after introducing dye into the aorta through a catheter. An aortogram is sometimes referred to as aortography. These two terms mean the same thing.
• Arteriogram: A more general term used to refer a set of images obtained in any artery in the body after introducing dye into that artery through a catheter. When the term “arteriogram” is used to refer to dye introduced into the aorta, arteriorgram is a synonym for aortogram and would mean the same thing in a report.
• Angiogram: An even broader term than arteriogram, an angiogram refers to a set of images obtained in any blood vessel in the body (artery or vein) after introducing dye into that blood vessel through a catheter. When the term “angiogram” is used to refer to dye introduced into the aorta, it is a synonym for aortogram and would mean the same thing in a report.
• Abdominal aortogram: A set of images of most or all of the abdominal aorta specifically taken after introducing dye into that part of the aorta through a catheter.
• Renal Artery Orifices: The place where the renal arteries connect to the abdominal aorta.
• Aortic Bifurcation: The place where the abdominal aorta ends and branches off into the right and left common iliac arteries.
• Infrarenal Aorta: Term used to describe the portion of the abdominal aorta below the renal artery orifices and above the aortic bifurcation.
• Distal Abdominal Aorta: Term generally used to describe the last few centimeters of the abdominal aorta right above the aortic bifurcation.
• Iliofemoral: A term used to refer to the iliac arteries and femoral arteries together. The iliac arteries are located just below the aortic bifurcation and help to supply blood flow to the legs and the pelvis while the femoral arteries are major arteries in the thigh that help supply blood flow to the legs.
• Lower Extremity Angiogram: A term used to refer to an angiogram obtained of the arteries of the legs. Lower extremity angiograms can be either unilateral (images of the arteries of one leg only) or bilateral (images of the arteries of both legs).
• Serialography: A technique that involves taking multiple images during an angiogram rather than a single image.

Now that we have some of the key terms outlined, let’s look at the description of the two codes we are discussing today:

• CPT 75625: Aortography, abdominal, by serialography, including radiological supervision and interpretation
• CPT 75630: Aortography, abdominal plus bilateral iliofemoral lower extremity, by serialography, including radiological supervision and interpretation

As you can see, CPT 75625 states “aortography abdominal” (referring to an aortogram of the abdominal segment of the aorta) by serialography. So CPT 75625 reports multiple pictures of the abdominal aorta by itself. This code can also be paired with codes for lower extremity arteriograms which we will see in a moment. CPT 75630 is for aortography again in the abdominal segment of the aorta, but it also includes imaging of the iliofemoral arteries bilaterally (both the left and the right sides are imaged).

Where much of the confusion comes in with these two codes lies in whether to code 75625 with a lower extremity arteriogram for imaging of the arteries of the legs (75710 or 75716) or whether to code 75630 alone. There are two keys to look for when trying to decipher these two codes:

1. How much of the arteries of the legs were imaged? To determine this, focus on the physician’s interpretation of the images. Is he/she talking only about findings in the upper legs (e.g., do they see the iliac arteries and femoral arteries alone), or are they talking about findings of arteries all the way down the legs (e.g., can you see findings of the below the knee popliteal and the tibial/peroneal arteries which lie in the calf)?
2. Where is the catheter at the time dye is introduced, and does that catheter “move” after obtaining the images of the abdominal aorta and before obtaining images of the arteries of the legs? With CPT 75630, the catheter is usually placed in one position towards the top of the abdominal aorta near the renal arteries, dye is introduced once from this one catheter position, and multiple images of the abdominal aorta, iliac, and femoral arteries are obtained. When coding CPT 75625 alone, the catheter is again placed near the top of the abdominal aorta near the renal arteries, dye is introduced from this one catheter position, and multiple images of the abdominal aorta alone are taken. From there the physician may move the catheter down to just above the aortic bifurcation or into the arteries of one or both legs and introduce more dye and then take more images/pictures of the arteries of the legs from this new catheter position(s). It is this movement of the catheter and introduction of more dye from that second catheter position followed by additional imaging that allows us to code 75625 and code 75710 or 75716 together, which tells the payer that the aortogram and the lower extremity artery angiograms were separate studies.

There are a couple of additional tips we need to keep in mind when coding for aortograms:

1. CPT codes from the radiology section of the manual like CPT 75625 and 75630 include “radiology supervision and interpretation.” That means that it is not enough for the physician to just tell us where the catheter is located and the fact that he is introducing dye and taking images/pictures (the supervision part). He also has to tell us what he sees on those images/pictures (the interpretation part) to be able to give credit for these CPT codes.
2. Per the CPT guidelines, all codes that have the language “radiology supervision and interpretation” in their CPT code description require images to be stored in the patient’s medical record. This means that if the physician introduces dye to visualize the arteries but doesn’t take any images that are stored (e.g., in a system like PACS), you cannot bill one of these codes with the term “radiology supervision and interpretation” in its CPT code description. During aortograms, physicians/hospitals do typically store their images (it would be very rare that they do not store images), but if you work for a coding/billing company where you are coding for clients and cannot see the images on file in the patient’s chart (e.g., you are coding from an electronic medical record and the images are stored in a separate PACS system that you cannot access), it is important to talk to your clients directly or to your management team internally and ensure they understand this rule and have confirmed that the clients are permanently storing all of their images before you proceed with coding and billing.
3. When you code an aortogram (either CPT 75625 or 75630), you are indicating that the physician is imaging most or all of the abdominal aorta (based on the definition of an aortogram). If the physician were to image just the last few centimeters of the abdominal aorta (the distal aorta only), he/she would not be meeting the definition of an aortogram. Incidental imaging of just those last few centimeters of the abdominal aorta wouldn’t be billed separately as an aortogram because the physician is not imaging enough of the aorta to confirm or rule out presence of disease in the abdominal aorta. Incidental imaging of those last few centimeters of the aorta just above the aortic bifurcation would be considered part of the lower extremity angiogram and not reported with an aortogram code.
4. These codes we are discussing today are for the radiology supervision and interpretation only (obtaining and interpreting the images). They do not include the placement of catheter(s) into the arteries or ultrasound guidance to gain access into the arteries. These procedures are reported with their own CPT codes. We are focusing today on the radiology codes for aortograms, but you can check your CPT manual for guidelines regarding coding your catheter placements and ultrasound guidance separately or head over to our “contact” portion of the Coding Mastery page and reach out if you have questions regarding coding this part of the procedure.

Okay let’s put this in context with a couple of examples and see if we can determine whether 75630 or 75625 is appropriate:

Example #1: The right femoral artery was accessed using Seldinger technique. A 6 French sheath was then inserted and advanced to the proximal abdominal aorta where contrast was introduced. An aortogram was obtained. The catheter was then withdrawn to the distal aorta where additional contrast was introduced. We then obtained images in a step-wise fashion in the bilateral lower extremities. Findings of angiographic imaging are noted below:

Aorta: The abdominal aorta is patent without significant plaque/lesions. The renal artery orifices are patent without significant stenosis.

Right Lower Extremity: The right common iliac artery has minimal plaque that is non-obstructing. The arteries are patent down through the right superficial femoral artery, but in the region of the above the knee popliteal artery, there is a high-grade stenosis (~70%). This artery reconstitutes below the knee. The tibio-peroneal trunk, anterior tibial, and posterior tibial arteries are patent, but the peroneal artery has stenosis on the order of 90%.

Left Lower Extremity: The left common iliac artery is severely stenotic with a near total occlusion just above the origin of the external iliac artery. The remaining arteries including the external iliac, femorals, popliteal, and tibial/peroneal arteries are patent with minimal plaque but no obstructing lesions.

The patient will be referred to vascular surgery to discuss revascularization options based on the left iliac, right SFA, and right peroneal findings.

Answer Coding Example #1: The bolded portions of the note are keys to selecting our CPT code. We first see the physician entering the femoral artery through Seldinger technique (which is a percutaneous approach). He then threads the catheter up into the “proximal” abdominal aorta (so he is up at the top of the abdominal aorta with his catheter). He then tells us that he obtains an aortogram (so the aortogram was obtained with the catheter in the upper part of the abdominal aorta). He then moves the catheter down to just above the aortic bifurcation and introduces more dye where he obtains the lower extremity angiograms. From there, we need to make sure we have an interpretation of findings in both the aorta and the lower extremity arteries. When we go to the findings, we first see findings of the aorta. The aorta is patent (or wide open/normal) and the renal artery orifices are patent as well without any stenosis. These findings confirm that the physician is seeing most of the abdominal aorta (all the way from where the renal arteries connect to the aorta down to the aortic bifurcation) so he has met the definition of an aortogram. When then see findings of the arteries in both of the legs all the way down the legs. The physician is talking about the iliac, femoral, popliteal, tibial, and peroneal arteries (these arteries extend from around the hip area all the way down to the ankle). With these findings from the imaging and confirmation of the fact that the physician first obtained an aortogram from one catheter position up at the top of the aorta and then the lower extremity angiograms of both legs from a second catheter position just above the aortic bifurcation after moving the catheter, we can code CPT codes 75625 and 75716.

Example #2: The left femoral artery was accessed using Seldinger technique. A 6 French sheath was then inserted and advanced to the proximal abdominal aorta where contrast was introduced. An aortogram with iliofemoral runoff was obtained. Findings of angiographic imaging are noted below:

Aorta: The abdominal aorta is patent from the renal arteries to the aortic bifurcation.

Right Lower Extremity: The right common iliac artery has minimal plaque that is non-obstructing. The external iliac, common and superficial femoral, and above the knee popliteal are patent throughout their course.

Left Lower Extremity: The left common iliac artery is patent, but the external iliac artery has a stenosis on the order of 60%. This reconstitutes at the level of the common femoral artery which along with the superficial femoral and above the knee popliteal arteries is patent.

We will discuss the possibility of angioplasty/stenting of the left external iliac artery.

Answer Example #2: We again see the physician entering the femoral artery through Seldinger technique (percutaneous access). He then threads a catheter up into the proximal aorta much like we saw in example #1. He then introduces dye into the aorta and takes images of the abdominal aorta, and “bilateral iliofemoral runoffs” (or images of the iliofemoral arteries on both sides as the dye travels downstream from the aorta and into these arteries). We see no documentation of catheter movement between obtaining images of the aorta and images of the bilateral iliofemoral arteries.

We then need to look at our findings to see what images were obtained and confirm that we have an interpretation of those images. We first see the findings of the aorta. Again the physician has confirmed that the aorta is patent from the renal arteries to the aortic bifurcation, confirming that he is seeing most of the abdominal aorta on these images. He then comments on the bilateral iliac arteries, femoral arteries, and even makes mention of the above the knee popliteal. All of these arteries are patent/normal except for the left external iliac artery where we see a 60% stenosis. Since the physician obtains images of most of the abdominal aorta and the bilateral iliofemoral arteries together from “one catheter position,” this documentation supports CPT 75630. As one final coding tip, the physician may see and comment on arteries below the femoral arteries in a procedure coded with CPT 75630 (as he did in this case where he’s commenting on the above the knee popliteal arteries). This confuses many coders because CPT 75630 states “bilateral iliofemoral arteries” only so often when coders see other arteries mentioned they are tempted to steer away from code 75630. However, if the physician is obtaining the combined abdominal aortic images plus the bilateral lower extremity artery images from a single catheter position, your code is still CPT 75630 even if the physician comments on some additional arteries other than the iliac and femoral arteries that he can see while obtaining his images of the aorta and bilateral iliofemoral arteries.

In our last article, we discussed the differences between a partial mastectomy and excision of a breast mass and what documentation you would need to code each scenario. If you haven’t checked out that article, you can do so here:
http://codingmastery.com/2019/05/04/distinguishing-lumpectomies-and-excision-of-breast-mass/ . 

Today, we are going to continue on the topic of surgeries of the breast with a discussion about image-guided percutaneous breast biopsies. The codes to report this procedure changed back in 2014, and coders often still have some questions about how to appropriately code this procedure as technology advances and physicians in different facilities perform part but not all of the work described by these codes.

Before we take a look at the codes, there are a few terms that you need to know to understand the code descriptions and guidelines for reporting this service:

• Percutaneous means to puncture through the skin.
• Stereotactic guidance in the context of these codes involves the use of low-dose mammogram images (aka x-rays of the breast) to locate a lesion for biopsy.
• Ultrasound guidance involves the use of ultrasound images to locate a lesion for biopsy
• MR guidance involves the use of magnetic resonance imaging (MRI imaging) to locate a lesion for biopsy.
• Tomosynthesis is an imaging technique that uses low-dose x-rays (i.e., mammogram images) along with computer reconstruction to create 3D images of the breast.
• A localization device is a device such as a clip or pellet that helps to identify an abnormality in the breast that is small and cannot be felt during an exam. These devices are used to help physicians locate these abnormalities for biopsy, removal, or future exams.
• Calcifications are calcium deposits in the breast that are visible on mammogram images. These calcium deposits may further be described as macrocalcifications (larger deposits of calcium) or microcalcifications (very tiny deposits of calcium).
• A mass or lesion is a generic term meaning an  abnormal accumulation of tissue. We will use the term “lesion” to refer to all different abnormalities that may be found in the breast tissue for the remainder of this article, but definitions of specific types of abnormalities are provided here so you understand the difference in these terms when you see them in physician reports.

Now that we have our terminology down, let’s take a look at the CPT codes available for percutaneous biopsies of the breast:

• CPT 19081: Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance.
• +CPT 19082: each additional lesion, including stereotactic guidance (list separately in addition to code for primary procedure).
• CPT 19083: Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance.
• +CPT 19084: each additional lesion, including ultrasound guidance (list separately in addition to code for primary procedure).
• CPT 19085: Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance.
• +CPT 19086: each additional lesion, including magnetic resonance guidance (list separately in addition to code for primary procedure).

As you can see, for each of the different types of imaging guidance that may be used during a percutaneous breast biopsy, we have one “parent code” to report the first lesion biopsied using that type of imaging guidance and then an add on code that is reported for each additional lesion biopsied using that same type of imaging guidance.

It’s also important to note that the physician “may” insert a localization device or “may” image the specimen that was removed to ensure the area of concern is included in the tissue removed. When these additional procedures are performed during the same encounter as the biopsy they are included in CPT codes 19081-19086 and should not be reported with separate CPT codes. These additional procedures though are not “required” to report these CPT codes. Anytime we see that a part of the code description is followed by the phrase “when performed” it is an optional service that may be performed but is not required in order to report the CPT code. The portions of the procedure description that must be performed to code CPT codes 19081-19086 is a percutaneous breast biopsy performed using the imaging guidance described by the code (e.g., stereotactic guidance).

Another important rule to know about these codes is how to report multiple biopsies during the same encounter. If more than one biopsy is performed using the same imaging guidance technique, you will report the parent code for the first lesion biopsied followed by the add on code for each additional lesion biopsied. This rule applies even if the two biopsies are in different breasts (i.e., a bilateral procedure with one procedure performed on the right breast and the other on the left). However, if multiple biopsies are performed during the same encounter and different image guidance techniques are used for each biopsy, you will report the parent code for each of the imaging techniques. For example, if a stereotactic-guided biopsy is performed on a lesion on the left breast and an ultrasound-guided biopsy on a lesion on the right breast, we would report CPT 19081 for the initial stereotactic biopsy on the left and CPT 19083 for the initial ultrasound guided biopsy on the right. Again it is the two different image guidance techniques that change how the case is coded.

Physicians have also started using tomosynthesis for guidance during percutaneous breast biopsies in recent years. Unfortunately, we do not have a code for performing a percutaneous breast biopsy using tomosynthesis. Some coders are inclined to report CPT codes 19081/19082 for a tomosynthesis-guided breast biopsy because this technique in part involves taking low dose x-rays (aka mammogram images). However, the remainder of the technique which involves using computer reconstruction with these mammogram images to create 3D images of the breast is not accurately described by these codes. The AMA has recommended reporting an unlisted code (CPT 19499) when tomosynthesis is the only image guidance technique used during the breast biopsy.

The CPT guidelines regarding image storage requirements were revised in 2019 to clarify that CPT codes in the surgery section of the CPT manual that include both the definitive procedure (e.g., biopsy) and image guidance or radiology supervision and interpretation (S&I) also require permanent storage of images from that imaging guidance or radiology S&I just as a radiology code for imaging guidance or radiology S&I alone would require permanent storage of images. The physician is not obligated to state in his/her report for the procedure that images were permanently stored, but this revision to the guidelines highlights the importance of having a conversation with your physicians or your coding management team to ensure that images are being permanently stored before reporting a code that requires this image storage.

As we have already discussed, CPT codes 19081-19086 all require the use of the imaging guidance listed in the code description to perform the biopsy. If a percutaneous needle biopsy of the breast is performed without the use of imaging guidance, report CPT 19100.

Finally, physicians will sometimes use image guidance to place a localization device without performing any biopsy of the breast during the same encounter. When the physician places a localization device alone without a percutaneous breast biopsy, report an appropriate code(s) from CPT range 19281-19288. We will not discuss these codes in detail in this article, but you can see a complete description in your CPT manual.

Let’s put this all together with a couple of examples to illustrate how to use these codes appropriately.

Example #1: The patient was brought back to the mammography suite and positioned appropriately on the stereotactic imaging table. Using stereotactic guidance the area of microcalcifications in the upper outer quadrant of the left breast was localized and a needle inserted into the area of concern. Three passes of the needle were performed to ensure an adequate specimen. After completion of the biopsy, the tissue removed was imaged and found to contain multiple clusters of microcalcifications confirming a successful biopsy. This concluded our procedure. Patient was instructed to call our office for a follow appointment in 7-10 days for results.

Coding for Example #1: The areas bolded in the note above are keys to our CPT coding. We first see that the physician is using “stereotactic guidance.” We then see that a single lesion (an area of microcalcifications in the upper outer quadrant of the left breast) was targeted for biopsy. We then see the physician passing a needle multiple times to get enough tissue while still using that stereotactic guidance. Note that even though “multiple passes” of the needle are made, the physician is still performing a biopsy of just one lesion/area of concern so this is still only counted as “one biopsy.” Finally, we see that the physician imaged the specimen removed to make sure it contained the microcalcifications. While this part of his procedure is not required per CPT guidelines, it is included when performed so we will not report any additional CPT code such as 76098 for this work. The CPT code supported for this procedure is CPT 19081.

Example #2: The patient was brought back to the interventional radiology suite. After sterile prep and drape, the area of calcifications in the right lower quadrant was imaged using MRI. The needle was then inserted using the MRI to guide the trajectory. Adequate tissue was obtained and a clip was inserted at the site of biopsy. Attention was then turned to a mass in the left inner upper quadrant. We brought in the ultrasound probe and localized the mass with a needle under ultrasound guidance. We obtained adequate tissue and concluded our procedure. Patient will follow up in 7-10 days for pathology results.

Coding for Example #2: The portions of the note above that are bolded are keys to our CPT coding. We see that the patient has an abnormality in the right lower quadrant. This initial lesion is approached with MRI guidance. We see the physician “inserting a needle using the MRI to guide the trajectory” (which confirms that the MRI is being used as guidance to get the needle to the right location). The physician then inserts a clip (a type of localization device) at the site of this biopsy. While inserting a localization device is not required to use this code, it is included when performed so we won’t report any additional code from range 19281-19288 for this work. We then see a second area of abnormality in the left inner upper quadrant. The physician switches from MRI guidance to ultrasound guidance during this second biopsy. We again see the ultrasound being used to “localize” (aka to locate) the mass and guide the needle into the mass. In this case, we will report CPT 19085 for the MRI guided biopsy on the right and CPT 19083 for the ultrasound guided biopsy on the left. Following our CPT guidelines, we will report the “parent code” for each lesion biopsied with a different type of imaging guidance.

For coders working with surgeons who specialize in surgical oncology, a common coding scenario you may need to decipher is whether to code excision of a breast mass (CPT 19120) or a partial mastectomy (CPT 19301).

Before we compare some examples and determine which code would be appropriate, let’s start by looking at the description of these two codes to compare them and understand why coders sometimes struggle to choose between these codes:

CPT 19120: Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions

CPT 19301: Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

The term “excision” that we see in the description for CPT 19120 means “to remove.” The excision described in this code is removal of some of the breast tissue due to an area of disease such as a mass/lesion, cyst, tumor, or benign or malignant neoplasm. As we move forward with the rest of the article, we will refer to all of these abnormalities as a “mass” to keep things simple, but there are some differences in what these terms mean clinically so you can check out the definition of each by hovering over the terms in the previous sentence if you like. The term “mastectomy” that we see in CPT 19301 also means “to remove” and specifically “to remove breast tissue” (mast- or masto- means “breast” and -ectomy means “to excise”). We also see the term “partial” following the word mastectomy clarifying that, while different terms may be used to describe the procedure represented by CPT 19301, including lumpectomy, quadrantectomy, etc., all of these procedure include removal of “part” of the breast rather than removal of the entire breast. As you can see, on the surface, both codes include excision of part of the breast. So how do you distinguish between the two codes and know which CPT to pick?

For CPT 19120, the physician is excising the breast mass alone. He/she isn’t overly concerned about whether they excised the “entire mass” or if they left a small part of the mass behind. The goal is just to “roughly remove” the mass. This procedure is usually performed in cases where the surgeon suspects that the mass is non-cancerous such as a cyst or fibroadenoma. This procedure may also be performed though when the surgeon is not sure if the tissue is cancerous or non-cancerous and wants to be conservative and not remove too much of the breast tissue until he/she has the final pathology report back and knows if additional excision is warranted. CPT 19120 is reported only once per breast whether one or more lesions are removed.

On the other hand, the key you are looking for in the operative report to assign CPT 19301 for a partial mastectomy is “attention to margins.” In CPT 19301, the surgeon must ensure that he/she has “negative margins” which involves removing the mass along with a rim of normal breast tissue around the mass to make sure no diseased tissue is left behind. That rim of normal tissue removed around the mass is called a margin (meaning “the edge”) because that normal tissue removed is around the outside edge of the mass in the final specimen removed. While a partial mastectomy is not always performed to treat cancer, breast cancer is one of the most common indications for a partial mastectomy since it is particularly important with cancer to ensure that you leave no diseased tissue behind and that you have “negative margins.”

Coding tip: Not every reference to the word “margin” in an operative report for excision of a breast mass refers to ensuring that the surgeon has “negative margins” as described above. Another reference you may see to the term “margins” is when the surgeon is marking a specimen for the pathologist. He/she may say that they “oriented the specimen” and “labeled the margins” (e.g., “I then used two sutures to mark the superior, inferior, and lateral margins”). This reference to the word “margin” does not automatically make this procedure a lumpectomy because it does not refer to the intent to obtain negative margins by taking a rim of normal tissue around the breast mass to ensure no diseased tissue remains after surgery. It is not uncommon for surgeons to mark and label the “margins” (or “edges” of the specimen) for a pathologist even in a case where a breast mass was excised without particular attention to margins. The surgeon marks the edges of the specimen in this way because he/she wants the pathologist to understand how that tissue was originally positioned in the patient’s body. This information is particularly useful should the pathology come back positive for cancer because it allows the surgeon and the pathologist to speak the same language in terms of identifying which margin/edge may still have cancer present and require further excision. In this example where the surgeon is simply labeling the margins/edges for the pathologist without taking additional tissue around the mass to ensure negative margins, you would code CPT 19120 not 19301.

Let’s try out what we’ve learned with a couple of examples:

Example #1: A 64 year old patient presents with a firm mass in the upper outer quadrant of the right breast. The mass by clinical exam and mammography is highly suspicious for cancer (mammogram is a BIRADS 4). Recommendation is for excision for final diagnosis and to determine if additional treatment is warranted.

After sterile prep and drape, a curvilinear incision was made in the vicinity of the mass in the upper outer quadrant of the right breast. Dissection was carried around the mass circumferentially ensuring to take additional tissue on all sides of the mass to ensure adequate resection. Frozen pathology was positive for invasive adenocarcinoma. The pathologist also relayed that the superior margin had cancer extending to 1 mm from the inked edge so an additional cut of tissue was taken from the breast superiorly. The incision was then closed in layers.

This concludes our procedure. Patient to follow up in the office in 7-10 days for suture removal and to receive final pathology results and discuss treatment options.

Coding for Example #1: The bolded portions of the note above are clues to selecting our CPT code. We first see the surgeon “circumferentially dissecting” (or cutting all the way around) the mass and that he “is ensuring to take additional tissue on all sides to ensure adequate resection.” This statement qualifies as attention to margins because he is taking additional normal tissue all the way around the mass and being careful to ensure he has complete resection and doesn’t leave any diseased tissue behind. While some surgeons will refer to taking “margins of tissue” around the mass others will describe something that means the same thing without ever using the word margin (this is a good example of a statement that does not use the word margin but does describe attention to margins). We then see the pathologist confirms this is cancer, and he’s a bit concerned that the superior (upper) part of the specimen may still have cancer too near the margin/edge on that side so the surgeon takes additional tissue on the superior edge of the cavity he’s created in the breast. This sentence further confirms the surgeon’s “attention to margins” but even without this sentence, the first statement about taking additional tissue to ensure adequate resection would support attention to margins. Based on these details, this example would be coded with CPT 19301.  I would also add modifier RT since this procedure occurs on the right breast, and CPT 19301 allows modifier 50 for a bilateral procedure on both sides per the Medicare Physician Fee Schedule (MPFS). When a code allows modifier 50, the laterality modifiers RT or LT would apply to that same code when the procedure described by the code is performed only on one side.

Example #2: A 27-year-old patient presents with a lump in the left lower quadrant of the left breast. Clinical presentation and ultrasound findings are consistent with a benign fibroadenoma. Patient was offered options of surgical excision vs. close interval monitoring with repeat ultrasounds and mammography. Patient has elected to have the area removed.

After sterile prep and drape, the area of concern in the left lower quadrant of the left breast was identified, and we made a circumferential incision around the palpable mass. The mass was excised and placed in formalin for transport to pathology. We carefully inspected our cavity and ensured hemostasis. The incision was closed in layers with sutures.

The patient will follow up in 7-10 days for a wound check and pathology results.

Coding for Example #2: The bold portions of the note above are clues to selecting our CPT code. This case starts similar to example #1 with a circumferential incision (an incision all the way around) the mass. From there though, we see that the surgeon excises the mass alone and sends it off for pathology which is typical anytime tissue is removed from the body. We see no excision of any additional tissue around the mass and no mention of the intent to ensure that no diseased tissue is left behind (no “attention to margins”). The goal is simply to remove the mass which is expected to be a benign area. This documentation supports CPT 19120. I would also add modifier LT since the procedure occurs on the left breast, and this CPT also permits modifiers 50/LT/RT per the MPFS.

Continuing our series on some notable changes to CPT this year, codes for biopsies of skin lesions have been expanded.

Prior to this year, we had two codes to represent a biopsy of a skin lesion: CPT 11100 for the first lesion biopsied and CPT 11101 for each additional lesion biopsied. When these codes were created many years ago, they were sufficient to accurately report the types of biopsies being performed at the time. As time has gone on, though, many different techniques for biopsying a lesion have emerged, and the work that goes into performing a biopsy can vary based on the technique used. For that reason, the AMA revised the skin lesion biopsy codes this year to more accurately describe the “method” for obtaining the biopsy.

Below are the new codes and their definitions. Notice that we have a primary or parent code for the first lesion biopsied for each method of biopsy and an add on code for each additional/separate lesion:

• CPT 11102: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); single lesion

• + CPT 11103: Tangential biopsy of the skin (e.g., shave, scoop, saucerize, curette); each separate/additional lesion (list separately in addition to code for primary procedure)

• CPT 11104: Punch biopsy of skin (includes simple closure when performed); single lesion

• +CPT 11105:  Punch biopsy of skin (includes simple closure when performed); each separate/additional lesion (list separately in addition to code for primary procedure)

• CPT 11106: Incisional biopsy of skin
  (e.g., wedge) (including simple closure, when performed); single lesion

• +CPT 11107: Incisional biopsy of skin
  (e.g., wedge) (including simple closure, when performed); each separate/additional lesion (list separately in addition to code for primary procedure)

To understand how to code with the expanded options available for this procedure, it is necessary to first understand some key definitions and rules for their use.

Key Definitions:

• The skin is made up of two layers of tissue. The epidermis is the outermost layer of the skin and provides protection against germs and a water-proof barrier to protect our inside organs. The dermis is the inner layer of the skin which lies between the epidermis and the subcutaneous tissue and provides toughness and flexibility for the skin.
• These different methods of biopsies may take a “partial thickness” sample of the skin (meaning only part of the layers of the skin in the area of the biopsy are removed, such as the epidermis layer only). Alternatively, they may take a “full thickness” sample of the skin (meaning the surgeon cuts through the epidermis and full thickness of the dermis down to the subcutaneous tissue to take a sample that includes all layers of the skin tissues).
• Tangential refers to a slicing motion with a blade. In this type of biopsy, the physician takes a “slice” of the skin and is taking a “partial thickness” sample of the skin lesion, usually taking only the epidermis. The physician may take part of the underlying dermal layer if needed, but in either case, is not cutting full thickness through the skin and taking epidermis and the full thickness of the dermal layer. Some synonyms for tangential include “curetting,” “scooping,” or “shaving” to obtain a biopsy, and you may see these terms used in procedure reports.
• A punch biopsy involves taking a “full thickness” column of tissue from a lesion using a punch tool. Punch tools come in different sizes so you may see a punch tool mentioned along with a size in millimeters (e.g., 12.0 millimeter punch tool was then used to obtain a biopsy)
• An incisional biopsy as the name suggests involves creating an incision with a blade. The incision may either be vertical or may involve cutting out a “wedge” of tissue. This type of biopsy is “full thickness” where tissue through the full thickness of the epidermis and dermis is excised and even the underlying subcutaneous fat may be removed if needed.

Key Guidelines:Now that we understand some key terms used in these code descriptions, we also need to be aware of rules about how the codes should be used.

• These codes can be used for biopsies anywhere in the body as long as the biopsy is of a “skin lesion.” The codes are not restricted to use for a specific anatomic site(s). For biopsy from tissues other than the skin, there are codes throughout the surgery section of CPT to represent those biopsies. For example, if a surgeon documented a biopsy of the anterior two-thirds of the tongue, you would report CPT 41100 rather than one of these skin biopsy codes.

• When coding more than one biopsy during the same case, you can only code one primary/parent code for the most extensive biopsy performed. You would then report all additional biopsies with add on codes. Example: A physician performs an incisional wedge biopsy of a lesion on the right forearm. He then performs a punch biopsy of a second lesion on the upper arm near the shoulder. In this example, you would code CPT 11106 for the most extensive biopsy technique (the incisional biopsy) and code add on code 11105 for the punch biopsy of the second lesion. How did I decide which primary biopsy and add on biopsy code to use? You can determine this both through checking your NCCI edits and your CPT guidelines. If I check NCCI edits between 11106 (first lesion incisional biopsy) and 11104 (first lesion punch biopsy), I see that CPT 11106 has higher total RVUs and is the column 1 (or more comprehensive) code in the NCCI edit. This confirms that the primary code CPT 11106 should be coded and that the punch biopsy should be reported with the add on code using NCCI edits. Your CPT parenthetical notes under these codes can also be useful guides to determining which primary codes the add on may be reported with. For example, underneath CPT 11105 (add on code for each additional lesion biopsied with a punch technique), it tells us to code first 11104 (a first lesion punch biopsy) or 11106 (a first lesion incisional biopsy). Underneath CPT 11107 though (add on code for each additional lesion biopsied with an incisional technique), it tells us to code first CPT 11106 (a first lesion incisional biopsy). So in our example here, we could not have reported CPT 11104 (first lesion punch biopsy) and CPT 11107 (add on code for each additional lesion biopsied with an incisional technique) without violating the CPT guidelines.

• The tangential biopsy codes which again involve a “slicing” of “shaving” motion can appear similar to other CPT codes like shave removals of lesions. To decide whether to code a tangential biopsy code or a shave removal code, look at the intent of the procedure. If the intent is to obtain tissue for a diagnosis/pathology, code the procedure as a tangential biopsy. If the intent is to completely remove the lesion, code the procedure as a shave removal.

• The biopsy codes include “simple closure” when performed. That means that it is not necessary for the surgeon to close the wound after the biopsy in order to use these codes, but that if he does so, and the closure is “simple” you do not get to report a separate code for that closure. The CPT guidelines define simple repair as “one layer closure” (meaning one layer of stitches is placed or techniques such as tissue glue that do not involve the use of stitches are used). In the rare event that a biopsy results in the need for a more extensive intermediate repair (i.e., layered closure where at least one layer is in the subcutaneous tissues or deeper) or complex repair (i.e., more than layered closure involving techniques such as debridement, stents, retention sutures, extensive undermining, or scar revision), you may report a separate CPT code for the repair.

Let’s look at an example together to put these definitions and guidelines into practice:

Example #1: A 30 year old male presents with a raised skin lesion on the right thigh that has grown and changed in color over the past few weeks. He is brought to the procedure room today for tissue diagnosis.

After prep and drape, local anesthetic was applied around the right thigh lesion. A scalpel was used to shave a 0.5 cm strip of epidermal tissue.from the lesion. Bleeding was controlled and patient tolerated the procedure well. He will follow up with me in 1 week for pathology results.

Answer example #1: The bold portions of the procedure note help us with our code selection. First of all we see in the history provided that the intent of the procedure is “tissue diagnosis” confirming this is a biopsy. We also see the indication is a “skin lesion” of the thigh confirming that we should select a code from the skin lesion biopsy codes in the integumentary section of CPT rather than from another section of the CPT manual.

From there, we see the surgeon using a scalpel (a type of blade) to “shave” epidermal tissue only. So the technique for biopsy is a “shave method” and this is a “partial thickness” sample since only the epidermal tissue is taken. These details confirm the biopsy type is tangential. Finally, we see again the physician stating the patient will follow up for biopsy results in 1 week, again confirming intent here is to obtain a biopsy.

Since we have only one skin lesion and that lesion is biopsied using a tangential technique, we will report CPT 11102. 

We are continuing our series on notable changes for CPT in 2019. Another area of the code manual that received a pretty extensive overhaul involved the codes for FNA biopsies. The acronym FNA stands for “fine needle aspiration.” In this technique, the surgeon typically aspirates fluid for biopsy using a fine gauge needle (he/she will often use a 22 or 25 gauge needle in this procedure). The surgeon then withdraws fluid (e.g., from a cyst) or may withdraw clusters of cells from a solid mass and that specimen is sent to pathology to obtain a diagnosis. The term “biopsy” was added to the FNA codes in 2019 to clarify that these codes should not be reported if the intent of the procedure is simply to drain fluid (there are other codes for fluid drainage in CPT). The intent of these FNA biopsy codes is to report use of a fine gauge needle to withdraw a specimen for purposes of biopsy (i.e., getting a diagnosis from the specimen).

In 2018, we only had two codes available for an FNA biopsy: CPT 10021 for an FNA biopsy without imaging guidance and 10022 for an FNA biopsy with imaging guidance. For CPT 10022 for the FNA biopsy with imaging guidance, you then had to add a second code to represent the exact type of imaging guidance used (77002 for fluoroscopy, 76942 for ultrasound, 77012 for CT guidance, or 77022 for MR guidance).

For 2019, though, we now have combination codes that capture FNA biopsy performed using specific types of imaging guidance (e.g., FNA biopsy with fluoroscopic guidance is all captured with a single code). The codes have also been designed to include primary codes for FNA biopsy of the first lesion and add on codes for each additional lesion where FNA biopsy is performed using the same type of imaging guidance.

Let’s start by looking at all of the new codes and their descriptions:

FNA Biopsy Without Imaging Guidance

10021  -Fine needle aspiration biopsy, without imaging guidance; first lesion

+10004 –Fine needle aspiration biopsy, without imaging guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy With Ultrasound Guidance

10005 –Fine needle aspiration biopsy, including ultrasound guidance; first lesion

+10006 –Fine needle aspiration biopsy, including ultrasound guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with Fluoroscopic Guidance

10007 –Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion

+10008 –Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with CT Guidance

10009 –Fine needle aspiration biopsy, including CT guidance;first lesion

+10010 –Fine needle aspiration biopsy, including CT guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with MR Guidance

10011 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

+10012 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

With the creation of these new codes for FNA biopsy, there are a couple of key guidelines to keep in mind:

• You can no longer report imaging guidance codes 77002, 76942, 77012, or 77022 with the FNA biopsy codes to report the imaging guidance used to perform the FNA biopsy itself or a core biopsy on the same lesion during the same encounter. Again the new combination codes already include the work of the FNA biopsy plus the specific form of imaging guidance in a single code. Coding tip: It would be permissible to report one of these imaging codes with an FNA biopsy code if the imaging was used to complete a procedure other than the FNA biopsy or a core needle biopsy on the same lesion during the same encounter.

• If “multiple passes” (i.e., multiple FNA biopsies) are obtained of the same lesion, you will still report only one unit of the FNA biopsy code that describes how that FNA biopsy was obtained. For example, if a surgeon performs an FNA biopsy under CT guidance for a nodule in the left thigh and he makes four passes into that nodule during the procedure to ensure he obtains adequate tissue for pathology, you will code CPT 10009 with only 1 unit. Even though four “passes” were made, he is biopsying just one lesion so you only code 1 unit of the CPT.

• When multiple lesions are addressed with FNA biopsy during the same encounter and all lesions are biopsied using the same type of imaging guidance, you report the primary code for the first lesion biopsied and report the add on code for the second and all additional lesions. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid also under ultrasound guidance, you will code CPT 10005 for the first nodule and CPT 10006 for the second nodule.

• When multiple lesions are addressed with FNA biopsy during the same encounter but lesions are biopsied using different types of imaging guidance, you report the primary code for the first lesion biopsied, picking the primary code that accurately describes the type of imaging guidance used, and then you report a second primary CPT code for the additional lesion biopsied using a different type of imaging guidance. Modifier 59 (or modifier XS if your payer like Medicare accepts the EPSU modifiers) will be required on the second primary CPT code to indicate that more than one site was biopsied. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid under fluoroscopic guidance, you will code CPT 10007 for the nodule biopsied using fluoroscopic guidance and CPT 10005 with modifier 59 (or modifier XS if the payer like Medicare accepts the EPSU modifiers) for the second nodule biopsied under ultrasound guidance. The coding is changed in this scenario because each nodule was biopsied using a different type of imaging guidance. Coding tip: I decided which CPT code needed the modifier 59 based on the NCCI edits. The modifier 59 would go on the column 2 code (i.e., the potentially bundled code in the NCCI edit pair). You can download a copy of the NCCI edit tables from Medicare’s website at the following link: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. When you get to the website, download all files that start with “Practitioner PTP Edits v25.0” (there are four files in total). You can also check edits in online coding software like 3M, Encoder Pro, and Supercoder (many coders find this to be an easier method of checking their edits). Just be sure to apply the modifier 59 (or XS) to your column 2 code.

I hope this article helps you to understand the changes for these codes in 2019 and how to use these codes correctly. If you have any questions about this topic or any of the new 2019 CPT codes that you would like to hear more about, head over to the “contact” tab and send me your question. I am always happy to hear from my readers and provide content that will help you in your daily work.