DecisionHealth, DecisionHealth - 2023 Issue 11 (November)

Q&A: How to code a vertebral bone biopsy prior to kyphoplasty

Question: Recently, we did a vertebral bone biopsy for a patient due to abnormalities on MRI. Once we have the results of the biopsy, we will then do a kyphoplasty. I need help determining the proper codes to use, both CPT and ICD-10-CM. The procedure note has ICD-10-CM code M84.58XA (Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture), but if we don’t have the biopsy results, I don’t feel we should give a metastatic/neoplastic diagnosis.

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