Can we charge for a fine needle aspiration (FNA) and core biopsy of the thyroid in the same session?
Generally, only a single biopsy, typically the more complex core biopsy, should be charged. The exception is when a pathologist immediately determines that the initial FNA aspirate is inadequate for diagnosis and a core biopsy is then obtained.
The National Correct Coding Initiative Policy Manual, Chapter 3, Subsection L indicates the following policy, and the Society of Interventional Radiology, American College of Radiology, and the American Medical Association have published similar statements.
11. Fine needle aspiration (FNA) (CPT codes 10021, 10022) should not be reported with another biopsy procedure code for the same lesion unless one specimen is inadequate for diagnosis. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the other biopsy procedure code may also be reported with an NCCI-associated modifier.