Coding Tip: Biopsy coding in PCS when fluid is aspirated
RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
The ICD-10-PCS Official Guidelines for Coding and Reporting 2017 added the terms “fluid in the” to help coders determine what root operation should be used when a biopsy is performed with only fluid removed.
Biopsies are coded to the root operations excision, extraction, or drainage (with the qualifier diagnostic). When only fluid is removed during a needle aspiration biopsy, the root operation would be “drainage”. The addition of the term “fluid” helps to clear up many questions that coders have had in the past year since ICD-10-PCS was implemented.
During a fine needle aspiration either fluid/gas or tissue can be removed. If tissue is obtained, the coder would need to determine the appropriate root operation of excision or extraction. If only fluid or gas is removed, the coder would follow the above and code to “drainage”.
An example that we see often is on page 5 of the updated ICD-10-PCS Official Guidelines for Coding and Reporting 2017 which includes fine needle aspiration of fluid from the lung. Another area that we see often is fine needle aspiration of fluid from ovary for biopsy. Only fluid is removed so this would be coded to the root operation of “drainage”. If this fine needle aspiration is performed during another open procedure, it would be coded as drainage of ovary, open approach, diagnostic.
The fact that the procedure is performed via open approach does not change the root operation for fluid removal for biopsy. However, even though the needle is used, the main procedure is done via open approach so the biopsy must be coded to open approach per CC3Q2016 page 41.
AHA Coding Clinic, Fourth Quarter 2016, Page: 135
ICD-10-PCS Official Guidelines for Coding and Reporting 2017
AHA Coding Clinic, Third Quarter 2016, Page: 41
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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