Coding Biopsies in ICD-10-PCS
By Bonnie G. Schreck, BS, CCS, CPC, COC, CP
January 11, 2016
When looking up ‘Biopsy’ in the ICD-10-PCS Alphabetic Index, it directs you to root operations drainage and excision with a diagnostic 6th character qualifier.
In the 2016 ICD-10-PCS Official Guidelines for Coding and Reporting
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.
Here is a biopsy of bone marrow, broken down by characters:
Character 1: Medical and Surgical Section
Character 2: Body System – Bone Marrow
Character 3: Root operation - In the Alphabetic Index, under the term ‘Biopsy,
Bone Marrow’, leads to the term ‘Extraction’, with qualifier ‘Diagnostic’.
Character 4: Body part - Which bone is the marrow extracted from, Iliac, Sternum, Vertebral
Character 5: Approach - Open or Percutaneous
Character 6: Qualifier – No Qualifier
Character 7: Qualifier – Diagnostic
Needle biopsy of bone marrow of the iliac crest: 07DR3ZX
The ICD-10-PCS Guidelines also give direction on the coding of biopsies accompanied by a definitive procedure.
Biopsy followed by more definitive treatment
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.
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