Improve Reimbursements by Fixing Biopsy Coding Mistakes
Learn how to detect and avoid common biopsy coding mistakes to prevent denials and ensure accurate reimbursements for your medical practice.
OB/GYN Medical Billing & Coding Alert
Are you confused as to why having modifiers 22 and 25 prepared is essential?
If you’re under the assumption that the number of samples taken by your OB-GYN directly correlates with the number of biopsy coding units to report. In that case, you could be setting yourself up for costly denials and unnecessary complications.
Take a look at these three scenarios to see if your approach aligns with expert recommendations.
The Importance of Accurate Biopsy Coding
Background: A biopsy is a tissue sample removed by an OBGYN to check for cancer. OBGYNs typically perform biopsies on areas such as the vulva, cervix, vagina, endometrium, and ovaries. These procedures are usually ordered when there are signs like abnormal vaginal bleeding or the detection of a mass, cyst, lump, tumor, or abnormal cells.
Best Practice: Always code biopsies with the pathology report to support your diagnosis. Making this a standard practice will help ensure your claims are processed smoothly and efficiently.
Lap-to-Open Biopsy Procedure Requires This Code
Scenario: An OBGYN performs a laparoscopic ovarian biopsy on the left side. The biopsy reveals malignancy, leading to the conversion to an open procedure to remove the ovary. What should you report?
What You Should Do:
- Laparoscopic Ovarian Biopsy: Report 49321 (Laparoscopy, surgical; with biopsy [single or multiple]).
- Conversion to Open Surgery: If the biopsy confirms malignancy and the OBGYN moves forward with open surgery to remove the ovary, use 58940 (Oophorectomy, partial or total, unilateral or bilateral).
Important Notes:
- No Omentectomy: Do not use 58950 (Resection of ovarian malignancy with bilateral salpingo-oophorectomy and omentectomy) because no omentectomy was performed.
- Separate or Combined Codes: Most payers will bundle the biopsy with the open surgery. However, some may reimburse 49321 separately, especially if the biopsy was essential for deciding whether the open surgery was needed (e.g., if the patient was not initially scheduled for an oophorectomy).
- Modifier 22 for Extra Work: If the laparoscopic biopsy was complex, consider adding modifier 22 (Increased procedural services) to 58940 for possible higher reimbursement.
Don’t Forget: Attach the correct diagnosis, such as C56.2 (Malignant neoplasm of left ovary), to support the oophorectomy. Never code malignancy without pathology confirmation.
Look for These Additional Coding Opportunities
Scenario: A patient with irregular intermenstrual bleeding (N92.1, Excessive and frequent menstruation with irregular cycle) undergoes an office procedure where the OBGYN extracts tissue samples from the lining of the uterus (endometrium). The OBGYN inserts a plastic catheter into the uterus and suction a small amount of the endometrial lining. What should you report?
What You Should Do:
This procedure is an endometrial biopsy, and the correct code to report is 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]). This code is for a straightforward procedure typically performed in the office, often without general or local anesthesia.
Keep in Mind:
- Modifier 25: If the OBGYN performs an additional, significant Evaluation and Management (E/M) service on the same day, attach modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the E/M code. However, if the patient only has the biopsy with no other services, report 58100 alone.
- Endometrial Biopsy with Colposcopy: If the OBGYN performs an endometrial biopsy during a colposcopy, use the add-on code +58110 (Endometrial sampling [biopsy] performed in conjunction with colposcopy [List separately in addition to code for primary procedure]) instead of 58100.
Count Your Lesions Carefully
Scenario: A patient presents with three mole-like lesions on the vulva that haven't responded to topical or other treatments. Using topical anesthesia, the OBGYN takes a sample from each of the three identified lesions. What should you report?
What You Should Do:
The correct codes for a vulvar biopsy are 56605 (Biopsy of vulva or perineum [separate procedure]; 1 lesion) and +56606 (Each separate additional lesion [List separately in addition to code for primary procedure]).
- 56605 is used for the first lesson.
- +56606 is an add-on code for each additional lesion. Since three lesions are biopsied, report +56606 twice (one for each additional lesion beyond the first).
- On the claim form, it would appear as:
56605
+56606 x 2
Important Notes:
- No Modifier for Add-On Codes: Do not use a modifier with +56606, as it is an add-on code and does not require one.
- Cervical Biopsy Exception: In cases like a colposcopy with a cervical biopsy, even if multiple samples are taken, only one code is submitted (e.g., 57455, Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix). The lab will handle billing for each specimen.
- Single Lesion Biopsy: If the OBGYN takes three samples from a single lesion, only 56605 should be reported.
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