Biopsy Services – Billing Guidelines

Hello and welcome to our podcast series. My name is Meghann Drella and I am a Senior Solutions Manager here at Outsource Strategies International. Today I will be discussing the billing guidelines for biopsy services.

Various types of biopsy procedures are used to make a cancer diagnosis such as bone marrow biopsy, endoscopic biopsy, needle biopsy, skin biopsy and surgical biopsy. Providers of biopsy services need to know how to properly bill and code for these procedures.

00:27 CPT codes for biopsy procedures

In 2019, a series of CPT codes for biopsy procedures were introduced which are specific to the method of removal – tangential, punch, and incisional. These codes will be attached to the document provided with this podcast.

• 11102 Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion
• +11103 each separate/additional lesion (List separately in addition to code for primary procedure)
• 11104 Punch biopsy of skin [including simple closure, when performed]; single lesion
• +11105 each separate/additional lesion (List separately in addition to code for primary procedure)
• 11106 Incisional biopsy of skin (e.g., wedge) (including simple closure, when performed); single lesion
• +11107 each separate/additional lesion (List separately in addition to code for primary procedure)

00:43 Types of biopsy procedures

• Tangential biopsies are performed with a sharp blade and shave, scoop or curette techniques are used to remove a sample of epidermal tissue, with or without a portion of the underlying dermis.
• Punch biopsies involve using a punch tool to remove a full-thickness cylindrical sample of the skin.
• In incisional biopsies, a sharp blade is used to make a vertical incision or wedge to remove a full-thickness sample of tissue, penetrating deep to the dermis and into the subcutaneous tissue.

01:13 Reports on increasing claim denials

Reports indicate improper billing and denials have increased. Medicare Administrative Contractor First Coast Service Options (FCSO) identifies the reasons for biopsy procedure claim denials as –

• When biopsy codes are billed with other surgery codes on the same date of service, modifier 59 is being appended to the other surgery code instead of the biopsy code.
• Biopsy codes exceed the CMS Medically Unlikely Edits (MUEs). An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.
• The wrong primary code is being billed or no primary code is being billed at all.
• Biopsy codes are billed with a screening diagnosis.

According to AAPC, CPT guidelines on coding biopsy services can throw light on why these codes are facing denials: use of the incisional, punch, and tangential biopsy codes indicates that the procedure was to obtain tissue for a “diagnostic histopathologic examination” and that the procedure was “performed independently or was unrelated or distinct from other procedures/services at that time.”

02:19 Tips to reduce claim denials

To obtain proper payment for biopsy services, follow these steps:

• Report CPT codes 11102-11107 only for diagnostic biopsies and do not bill these codes with a screening diagnosis.
• Apply the appropriate modifier for the appropriate code.
• Report the appropriate primary code.
• Know the rules for reporting multiple biopsies.
• If multiple biopsies are performed using the same technique, report the primary code with the highest RVU.
• When billing for biopsy services, document the method, the number of units, and the location.
• Ensure that the maximum units of service that can be reported for a single patient on a single date of service is not exceeded.

I hope this helps but always remember that documentation as well as a thorough knowledge of the payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank you for joining me and stay tuned for my next podcast.