by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC

Biopsy and Aspiration of a Left Parotid

Question:

Would I use CPT 42400, 76942, and 10160?

Ultrasound of the left parotid region was performed. The cyst was identified and multiple images were stored. The skin was prepped using ChloraPrep, and allowed to dry before sterile draping applied in the usual sterile fashion. Using lidocaine for local anesthesia as well as direct ultrasound guidance, using an 18 gauge Biopince needle, 2 core biopsies were performed obtaining tissue from the periphery of the cyst. Next, an 18-gauge needle was used to aspirate 5 mL of red fluid from the cyst itself. Ultrasound images of needle entry were saved and sent to PACS. A sterile dressing was applied. The patient remained stable during and immediately after the procedure.

Impression: Ultrasound-guided percutaneous core biopsy and aspiration of a left parotid cyst.

Answer:

I would report 76942, 10160, and 42400 with a couple of caveats. The report describes an US-guided core biopsy, so that is 76942 and 42400. Next an aspiration is defined. Since they don’t describe an aspirational biopsy, I would go with 10160 for that portion of the procedure. Per CMS NCCI instructions, only a single unit of a guidance code can be reported.

“CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes 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.”

I would query the provider more on what type of aspiration was done: an aspirational biopsy (then see 10005 and drop the 76942 but keep the 42400) or an aspiration of the cyst itself (keeping the original three codes I listed).


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