tci Outpatient Facility Coding Alert - 2015 Issue 10

Reader Question: Know The Reason if You Want To Club Fine Needle Aspiration With Another Biopsy Procedure

Question: The physician performed a fine needle aspiration and then a needle biopsy of the same lesion at the same session. Should I report both? Virginia Subscriber Answer: The answer depends on why the physician performed both procedures (and, as always, the individual payer policy). For Medicare and other payers who follow Correct Coding Initiative (CCI) policies, you should report both services only if the fine needle aspiration (FNA) specimen isn’t adequate and therefore there is medical necessity for another type of biopsy. The CCI Policy Manual gives this rule in Chapter 3, Section 10 (

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