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.

Reference: References: ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021 Section B3.4b: Biopsy followed by more definitive treatment
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