Health Information Management

Coding for biopsies in ICD-10-PCS

HIM-HIPAA Insider, January 13, 2014

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Ann came in to Stitch ‘Em Up Hospital for a breast biopsy to confirm a diagnosis of breast cancer. Dr. Richards performed the biopsy and based on the results, decided to perform a partial mastectomy.
Can you code both the biopsy and the mastectomy? In ICD-10-PCS, the answer is yes.
According to guideline B3.4b:
If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded.

Let’s start by looking at how to code the biopsy. When you look up biopsy in the ICD-10-PCS Alphabetic Index, you are directed to root operations drainage and excision with a diagnostic qualifier. The qualifier diagnostic is used only for biopsies.

The type of biopsy will determine the root operation. If the physician is removing fluids or gases, use root operation drainage. If the physician is removing a portion of a body part, the root operation is excision. In Ann’s case, Dr. Richards is performing an excision. She is taking out a small piece of a mass to confirm the diagnosis. That gives us table 0HB.

Next, we need to know which breast Dr. Richards is taking the biopsy from in order to determine the  body part (character 4). We have six possible choices:
  • T, breast, right
  • U, breast, left
  • V, breast, bilateral
  • W, nipple, right
  • X, nipple, left
  • Y, supernumerary breast
We also need to know the approach. For most of the body parts in table 0HB, we only have one approach: external. For a breast biopsy, we have these five:
  • 0, open
  • 3, percutaneous
  • 7, via natural or artificial opening
  • 8, via natural or artificial opening endoscopic
  • X, external
Most physicians should already be documenting the approach, but they may not being calling it via natural or artificial opening or percutaneous. As a result, you need to understand how ICD-10-PCS defines each approach and what words your physicians commonly use.

If Dr. Richards performed a needle biopsy of the right breast, we would report 0HBT3ZX (excision of right breast, percutaneous approach, diagnostic).

We would also code Ann’s partial mastectomy. We would again use the root operation excision because Dr. Richards is removing part of Ann’s breast. If Dr. Richards performed a total mastectomy, we would use the root operation resection.

Again we need to know which breast and the approach. We already know Dr. Richards is operating on the right breast. If she uses an open approach, the correct code would be 0HBT0ZZ (excision of right breast, open approach).

Make sure you read the important sections of the operative report closely so you can assign the correct root operation, body part, and approach.

This article originally appeared on
HCPro’s ICD-10 Trainer blog.


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