Typically, you may not separately report a biopsy performed with an excision, destruction, or other removal procedure. Medicare specifies two exceptions to this rule, however, as described in Chapter 1 of the National Correct Coding Initiative (NCCI), "General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services."

Exception 1.

"If the biopsy is performed on a separate lesion, it is separately reportable. This situation may be reported with anatomic modifiers or modifier 59."
The CPT® codebook mirrors this advice, stating, "&biopses are not considered components of other procedures when performed on different lesions or different sites on the same date, and are to be reported separately."

For example, if the provider biopsies a lesion on the right breast, and excises a lesion on the left breast, the biopsy may be reported separately because it occurred at a different location. Depending on payer preference, you may report the appropriate excision code with modifier LT Left side and the appropriate biopsy code (e.g., 11000 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion) with modifier RT Right side; or, you may report the excision code (which represents the more extensive procedure) without a modifier, and append modifier 59 Distinct procedural service to the biopsy code.

The AMA's CPT Assistant (October 2004) specifically addresses a scenario similar to that of our example, and supports separate coding of the biopsy:

In cases where a biopsy is performed on one lesion and another lesion is excised, both the code for the biopsy (11100) and the appropriate code for the excision may be reported. The biopsy on one lesion is not considered a part of the other procedure performed on a different lesion on the same day. Therefore, each procedure may be reported separately. To further support this distinction, it is important to link the relevant diagnosis to each procedure on the claim to indicate the specific reason each was performed. Modifier 59 should be appended to the biopsy code to indicate that this was a separate procedure.

Exception 2.

"If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination&. When separately reportable modifier 58 may be reported to indicate that the biopsy and the more extensive procedure were planned or staged procedures."

In plain language, if the results of the biopsy prompt the provider to perform a more extensive procedure, you may report both the more extensive procedure and the biopsy.

For example, if the provider excises a suspicious lesion on the left, upper arm and sends it to pathology to confirm a diagnosis, the biopsy is not reported separately because, as NCCI General Correct Coding Policies explain, "If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure." The CPT® codebook similarly instructs, "The obtaining of tissue for pathology during the course of these procedures [excision, destruction, shave removals, etc.] is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported."

In an alternate example, the provider biopsies a suspicious lesion and sends the sample for pathologic exam. Based on a result of malignancy, the provider decides excise the entire lesion. In this case, because the biopsy led to the decision to perform the more extensive procedure, both the excision (e.g., 11602 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm) and the biopsy (11100) may be reported. You must append modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period to the excision code (11603) to notify the payer that the excision was a "more extensive" procedure, in addition to the biopsy.

Once again, CPT Assistant confirms the NCCI guidelines, and allows you to report 11100 separately when biopsy prompts a follow-up excision, as in this example from the March 1997 issue:

A 27-year-old male surfing champion notices an enlarging dark nodule on his right lower leg. Physical exam demonstrates a pigmented, variegated color 2cm skin lesion that is suspicious for melanoma. Under local anesthesia, a punch biopsy is performed for histologic diagnosis and to determine the Breslow depth of the lesion. Malignant melanoma 0.8 mm in depth is confirmed. Wide excision is planned for definitive treatment.

The General Correct Coding Policies provide additional instruction to help clarify biopsy billing:

• The biopsy is not separately reportable if the pathologic examination at the time of surgery is for the purpose of assessing margins of resection or verifying resectability.
• If a single lesion is biopsied multiple times, only one biopsy code may be reported with a single unit of service.
• If multiple lesions are non-endoscopically biopsied, a biopsy code may be reported for each lesion appending a modifier indicating that each biopsy was performed on a separate lesion.
• For endoscopic biopsies, multiple biopsies of a single or multiple lesions are reported with one unit of service of the biopsy code.
• If it is medically reasonable and necessary to submit multiple biopsies of the same or different lesions for separate pathologic examination, the medical record must identify the precise location and separate nature of each biopsy.

By keeping these guidelines in mind, you can both ensure optimal reimbursement for services provided, while minimizing the opportunity for negative audit findings or payer take-backs.

John Verhovshek, MA, CPC, is Managing Editor at AAPC, which has provided education and certification for over 100,000 healthcare business professionals. www.aapc.com