Cracking the Code

Biopsy Followed By Definitive Procedure

For inpatient medical coders, it is important to follow the ICD-10-PCS coding guidelines when reporting medical procedures. Per coding guidelines, if a diagnostic biopsy is followed by a more definitive procedure, then it is appropriate to report both the biopsy and the more definitive treatment. When a provider’s documentation states that an excision, extraction, or drainage procedure (biopsy) was performed and a destruction, excision, or resection is completed as well at the same procedure site, then both procedures should be reported.

Q: A 40-year-old male patient was admitted with cough, blood-stained sputum and a mass in the left lung. He underwent a percutaneous needle biopsy of the upper left lung lobe. Results of the tissue biopsied revealed Adenocarcinoma of the lung. During that same admission, he underwent an open resection of the left upper lung lobe.
A: 0BTG0ZZ, resection of left upper lung lobe, open approach
0BBG3ZX, excision of left upper lung lobe, percutaneous approach, diagnostic
Reference: ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021 Section B3.4b: Biopsy followed by more definitive treatment
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