ICD-10-PCS: Biopsy

ICD-10-PCS: Biopsy: With or without a Definitive Procedure

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June 25, 2015

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 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

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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

X DiagnosticZ No QualiferZ No Device

1 Trachea2 Carina3 Main Bronchus, Right4 Upper Lobe Bronchus, Right5 Middle Lobe Bronchus, Right6 Lower Lobe Bronchus, Right7 Main Bronchus, Left8 Upper Lobe Bronchus, Left9 Lingula BronchusB Lower Lobe Bronchus, RightC Upper Lung Lobe, RightD Middle Lung Lobe, RightF Lower Lung Lobe, Right

Body Part Approach Device Qualifier


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Biopsy of bone marrowWhat 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


Scenario: Needle biopsy of bone marrow of the iliac crest

Fine needle aspiration (FNA) biopsy of middle lobe of right lung 0B9D3ZX


Medical and SurgicalLymphatic and Hemic SystemsExtraction: Pulling or stripping out or off all or a portion of a body part by the use of force

07D

0 Open3 Percutaneous

X DiagnosticZ No Qualifer

Z No DeviceQ Bone Marrow, SternumR Bone Marrow, lliacS Bone Marrow, Vertebral


Needle biopsy of bone marrow of the iliac crest 07DR3ZX

Lymph node samplingWhat 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


Scenario: Percutaneous lymph node sampling of left axillary lymph node


0 Open3 Percutaneous4 Percutaneous Endoscopic


Z No Device

0 Lymphatic, Head1 Lymphatic, Right Neck2 Lymphatic, Left Neck3 Lymphatic, Right Upper Extremity4 Lymphatic, Left Upper Extremity5 Lymphatic, Right Axillary6 Lymphatic, Left Axillary7 Lymphatic, Thorax8 Lymphatic, Internal Mammary, Right9 Lymphatic, Internal Mammary, LeftB Lymphatic, MesentericC Lymphatic, PelvisD Lymphatic, Aortic


Medical and SurgicalLymphatic and Hemic SystemsExtraction: Cutting out or off, without replacement, a portion of a body part

07B

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:

“… a needle biopsy of the left breast.”

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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


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


Z No DeviceT Breast, RightU Breast, LeftV Breast, BilateralW Nipple, RightX Nipple, LeftY Supernumerary Breast


“... a needle biopsy of the left breast.” 0HBU3ZX

“…an open partial mastectomy of the left breast.”


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


Z No DeviceT Breast, RightU Breast, LeftV Breast, BilateralW Nipple, RightX Nipple, LeftY Supernumerary Breast


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

Documents

ICD-10-PCS: Biopsy