tci General Surgery Coding Alert - 2018 Issue 7

You Be the Coder: Don't Confuse Cyst and FNA Aspirations

Question: If a surgeon performs a breast-cyst aspiration and submits the aspirate to pathology for evaluation, should we bill the service as 10021? Texas Subscriber Answer: No, 10021 (Fine needle aspiration; without imaging guidance) is not the best code to describe a breast-cyst aspiration procedure. Instead, you should report 19000 (Puncture aspiration of cyst of breast). Although the procedures are similar — the surgeon inserts a needle and withdraws fluid — the purpose and details of the procedures differ. The intention of a 19000 service is a treatment for the cyst, to drain it. The surgeon may or may...

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