tci General Surgery Coding Alert - 2014 Issue 10

You Be the Coder: Beware Thyroid FNA and Needle Biopsy Together

Question: For a thyroid case, the op report shows that the surgeon performed a fine needle aspiration, but the pathologist stated that the specimen was inadequate. During the same session, the surgeon performed a core needle biopsy of the thyroid. Can we report both procedures?  SuperCoder Subscriber Answer: The answer depends on whether the two procedures are from the same site on the thyroid, or if, for example, one is from the left lobe and one from the right lobe.   If the procedures are from different sites, you should list the fine needle aspiration (FNA) as 10021...

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