If your oncologist takes both a bone marrow biopsy and a bone marrow aspiration, whether you’ll see Medicare reimbursement depends on the two guidelines below. But watch out: With OIG scrutiny and a HCPCS twist, these guidelines will put your coding savvy to the test.
Append 59 for Different Sites and Encounters
Because a bone marrow biopsy and a bone marrow aspiration can provide different diagnostic information for certain leukemia evaluations, taking both specimens from the same patient on the same day isn’t unusual, according to R.M. Stainton Jr., MD, president of Doctor’s Anatomic Pathology in Jonesboro, Ark.
Snag: Medicare and some other payers use the Correct Coding Initiative (CCI) edits to restrict how you bill for “sequenced” surgical procedures through the same incision. For biopsy and aspiration, CCI bundles the following codes:
- 38220 — Bone marrow; aspiration only
- 38221 — … biopsy, needle, or trocar.
Silver lining: You may report 38220 and 38221 together, according to the NCCI Policy Manual for Medicare Services, Chapter 5, Section E, if the physician performs the procedures at either of the following
- Different patient encounters
- Different sites, meaning “in different bones or two separate skin incisions over the same bone.”
For CMS and other payers who use the CCI edits, if these two procedures meet one of the above listed criteria, you may override the edit by appending modifier 59 (Distinct procedural service) to 38220 and receive payment for both services, Stainton says.
Additional 59 support: CMS posted “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service” on its CCI overview Web page. In the article, you’ll find the following examples, which echo the CCI manual criteria, of when CMS considers modifier 59 use to be appropriate for...
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