Percutaneous Breast Procedures Handout May 22, 2014 Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H

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1 Percutaneous Breast Procedures Handout May 22, 2014 Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H Agenda Biopsies Localization Procedures Other Issues Tomo Now & the Future Percutaneous Procedures Percutaneous minimally-invasive or interventional breast procedures generally include both the procedure and the imaging guidance Big changes for 2014 Most codes are now bundled and include everything Others can still be assigned a surgical and an imaging code Breast Biopsies o Needle Core o Stereotactic o Rotating Biopsy Device o Vacuum-Assisted Localization Devices Fine Needle Aspirations Cyst Aspirations Image Guidance o Ultrasound o Stereotactic o Mammographic (localization only) o MR o No codes for CT Codes Deleted for 2014 from the publisher. All rights reserved. Page 1

2 Breast Biopsies Codes Separate codes for biopsies utilizing: o Stereotactic guidance o Ultrasound o MR Covers all percutaneous image-guided needle code biopsies of the breast o Includes Mammotome, ATEC, ABBI and other vacuum-assisted or rotating devices Summary No codes for mammographic guidance No codes for CT procedures One option is to use Watch for guidance and payor policies Codes include the following services o Use of imaging guidance o Placement of a localization device (if performed) o Includes metallic clips as well as pellets o Specimen imaging (if performed) Includes multiple samples from single lesion Biopsies from separate lesion can be coded separately from the publisher. All rights reserved. Page 2

3 CCI edits bundle the following into these codes: o FNA ( ) o Localization device placement (19281, 19283, 19285, and 19287) o Specimen x-ray (76098) o Image guidance (e.g., 76942, 77002, 77012, etc.) When more than 1 biopsy is performed using the same imaging modality, use the add-on code If 2 lesions are biopsied using different imaging modalities assign two base codes Use modifier 50 for bilateral procedures unless directed differently by your payor Example 1 Mammotome biopsy of a lesion in the patient s right breast under stereotactic guidance with placement of a localization clip and specimen x-ray Example 2 Ultrasound-guided needle core biopsy of two lesions in the patient s left breast, with placement of localization clips and ultrasound exam of the biopsy specimens (first lesion), (addition lesion) Example 3 MRI-guided needle core biopsy of a lesion in the patient s left breast and ultrasound-guided biopsy of a lesion in the right breast, with placement of localization clips (first lesion, MR), (first lesion, US) Breast Localization Procedures Designed to address placement of localization devices when a biopsy is not performed Includes o Placement of a needle localization wire prior to open surgical biopsy o Placement of a clip or radioactive seed into the breast as a stand-alone procedure o Placement of a localization device following FNA of the breast (if permitted by payor guidelines) o Placement of fiducial markers (per Clinical Examples) from the publisher. All rights reserved. Page 3

4 Includes placement of 1 or more devices for a single lesion For example, placement of 2 bracketing needles around a single lesion Imaging is included and should not be reported separately Clip removal should be reported with CCI edits bundle the following into these codes: o Mammogram codes bundle into mammographic guidance codes o Base code for MR guidance bundles the base codes for mammo guidance, stereotactic and US guided localization device procedures o Base code for US bundles the base codes for mammo and stereotactic guided procedures o Base code for stereotactic device placement bundles base code for mammo guidance CCI edits localization codes into the FNA codes o Instead of the other way around If localization devices are placed in multiple lesions in the same breast using the same imaging modality the first lesion is reported with the base and each additional lesion is reported using the add-on code If localization devices are placed in 2 lesions using two different guidance modalities, use 2 base codes Use modifier 50 for bilateral procedures unless directed differently by your payor from the publisher. All rights reserved. Page 4

5 Example 4 Preoperative placement of needle localization wires in two lesions in the left breast under mammographic guidance (first lesion), (additional lesion) Example 5 Placement of localization devices into two breast lesions, one under stereotactic guidance and one ultrasound guidance (first lesion, stereotactic), (first lesion, US) Cyst Aspiration(s) No code changes for 2014 Usually performed with US or MR CPT and CMS guidance differ regarding bilateral status of o CMS states no modifier 50 for o AMA/CPT indicates that should be billed 2x for bilateral procedures Fine Needle Aspiration(s) FNA, with imaging guidance Cells obtained from non-palpable & certain palpable tissues May require several passes to obtain cells Includes smear preparation Imaging guidance is reported separately Postbiopsy Mammograms Performed to: o Verify the clip deployment o Document the exact location of the clip in relation to the biopsied cavity, and o Look for postbiopsy complications In the NCCP Manual for 2014 o If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281, 19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, , G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure. o In this Manual many policies are described utilizing the term physician. Unless indicated differently the usage of this term does not restrict the policies to physicians only but applies to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT codes pursuant to applicable portions of the Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR), and Medicare rules. In some sections of this Manual, the term physician would not include some of these entities because specific rules do not apply to them. For example, Anesthesia Rules and Global Surgery Rules do not apply to hospitals. from the publisher. All rights reserved. Page 5

6 Follow payor guidelines o Medicare o Commercial In the absence of written payor guidelines follow ACR/AMA guidelines o US or MR guided: Can always bill o Stereotactic: Only if patient is moved to dedicated unit o Mammographic: Not separately billed (included in guidance) Radiologist o One exception o If the radiologist did not perform the bx then they can always report the mammo regardless of modality In a non-hospital setting there must be an order for the post-procedure mammogram from the patient s treating physician o MQSA requires the facility to notify the patient about the results of any diagnostic mammogram o Including one performed following a procedure from the publisher. All rights reserved. Page 6

7 Example 6 US guided FNA of both breasts with core biopsy and clip placement in the RT breast with postprocedure direct digital mammogram Taken from ACR/AMA Clinical Examples in Radiology Spring 2014 Initial FNA specimen in the RT breast was deemed inadequate for diagnosis by the interpreting on-site pathologists, resulting in need for a core biopsy. Considerations: o FNA is allowed if initial sample is inadequate thus requiring a core biopsy Reported once per lesion Guidelines state that modifier 50 must be applied for bilateral aspirations; however Medicare does not recognize as bilateral so 2 units will be reported instead of modifier 50 Multiple passes through the same lesion is still coded as 1 aspiration o US guidance for FNA should be reported for each lesion aspirated regardless of whether it is in the same breast or different breasts This image guidance is not included in the bx code(s) o Ultrasound guidance reminder for Medicare CMS payment policy allows 1 unit of service for codes (US), (fluoro), (fluoro spine), (CT), and (MR) when the services are performed at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations. So only 1 unit of can be assigned for bilateral FNA procedures o Ultrasound guidance non-medicare Follow payor guidelines AMA guidelines allow US guidance to be reported for each lesion aspirated regardless of the number of passes made in each lesion Modifier RT, LT and/or 59 should be applied per payor guidelines to the additional codes to designate separate and distinct services Code Assignment : Bilateral FNA (or x2 depending on payor) x2: US guidance for bilateral FNA RT: US Guided Breast Biopsy G0206: Post procedure mammogram Apply modifiers according to payor policy/ Only 1 unit of if Medicare from the publisher. All rights reserved. Page 7

8 Hot Topics Have all the Correct Coding Initiatives (CCI) edits for the new codes been corrected? The erroneous CCI edits were deleted in the 2 nd quarter updates. Specifically the edits that bundled the base codes for localization device placement into the add-on codes for additional lesions (e.g., into 19282) were appropriately corrected. Confirm with your payor how to correct/address specific claims of concern. What are the biggest areas of concerns for edits? All of the new biopsy and localization codes have an MUE (medically unlikely edit) limit of 1 so if the same procedure is performed bilaterally you will need to apply modifier 50 rather than reporting 2 units or modifiers RT/LT to prevent being underpaid if the limit is applied to the date of service rather than to the claim line. How do we bill if our radiologists perform the imaging guidance but not the biopsy (or localization procedure)? New biopsy codes were designed to be reported by one physician. Per ACR only a single provider (NPI) can be reported on the CMS-1500 claim form and submitted to the carrier. Per the claim form instructions, the physician submitting the 1500 form certifies that he or she performed the entire service. How do we bill for breast biopsies in our IDTF? Previously IDTFs could bill for the imaging guidance; however, now most contractors will not permit IDTFs to bill for the new comprehensive codes. Currently there is no authoritative guidance from CMS specifically for this issue. It is important that you discuss this issue with your contractor and ensure any billing arrangements that you have/implement are reviewed by appropriate healthcare regulatory counsel. from the publisher. All rights reserved. Page 8

9 Tomosynthesis X-ray tube rotates around the breast taking pictures at different angles Uses digital mammography to obtain 3D image of the breast In the 4 th Quarter 2013 CMS issued a statement that since DBT procedures produce direct digital images, it is appropriately reported using one of the three existing HCPCS codes Medicare patients should not be asked to pay for DBT over and above what Medicare allows for the mammogram Non-Medicare o Can perform full-field digital mammograms (2D) or DBT 3D or both in combination to obtain during a single compression o Hologic C-View can now generate 2D images from the 3D DBT dataset allowing both to be obtained from a single exposure o Assign direct digital codes + unlisted code o Coding depends on which technique is used 2 Acquisitions vs. 1 Acquisition o Separate Acquisitions Report the 2D HCPCS digital code Report 3D acquisition with unlisted code If CAD performed assign or Do not assign a separate 3D code Example: Unilateral diagnostic digital mammo w/dbt and CAD o G0206 Unilateral mammo o DBT o CAD o Single Acquisition Report 3D DBT acquisition with unlisted code Report the reconstruction of the 2D digital mammo with HCPCS code No CAD is available for this type of exam so no CAD code is assigned Example: Unilateral diagnostic digital DBT with reconstruction of 2D digital mammo images using Hologic C-View o DBT o G0206 Unilateral mammo New Codes for 2015 Anticipate 3 new Category I codes tomosynthesis for 2015 o Bilateral diagnostic o Unilateral diagnostic o Screening The current mammo codes do not include the added physician work or practice expense involved in DBT 2 new codes requested to describe complete and limited breast ultrasound procedures o Aimed at addressing screening studies from the publisher. All rights reserved. Page 9

10 Speaker Contact Information from the publisher. All rights reserved. Page 10