Thyroid biopsy is used to find the cause of a nodule in the thyroid gland.. Thyroid gland located in neck, plays an important role in human body. The biopsy of thyroid gland helps in finding the diagnosis in thyroid gland. In Interventional radiology medical coding, CPT code for ultrasound guided biopsy of thyroid is frequently used. For diagnostic radiology, CPT code 76536 and 60100 are used for coding neck or thyroid ultrasound and thyroid biopsy respectively.

In some cases based on documentation, fine needle aspiration CPT code is used while coding thyroid biopsy. When the exam is performed on cells we need to report FNA CPT and for tissues we have to report core biopsy.

For any simple diagnosis, intially a thyroid or neck ultrasound (CPT 76536) is performed in radiology. For pathological examination of tissues, thyroid biopsy is performed. So, let use learn the guidelines to code CPT code for ultrasound guided biopsy of thyroid.

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Use of Cpt Code 60100 (ultrasound guided thyroid biopsy)

Procedure Code for ultrasound guided thyroid biopsy is different from the simple procedures. This is a core biopsy procedure done on thyroid gland. In Core biopsy of small sample of tissue is removed from thyroid. If the sample is taken from the nodule in thyroid, tests will be performed to find whether the nodule is benign or malignant. Therefore, Core biopsy of thyroid may help in finding the non-cancerous (benign) and cancerous (malignant) cells. Now, to reach out to CPT code for ultrasound-guided biopsy of thyroid, we have to code two codes. First code 60100 is used for the core biopsy of thyroid. Second code we will use for guidance 76942(ultrasound guidance).

Ultrasound is used to guide accurate placement of the needle within the thyroid nodule.

Cpt Code for Fine Needle aspiration of thyroid

Fine needle aspiration is performed with a very fine gauge needle usually from 25 to 27 gauge 1.5 inch. The needle is thin and the needle gauge is smaller is diameter than the normal needles. Now, this is a minimal invasive procedure, hence to perform this procedure we also used guidance. Ultrasound guidance is generally used in Fine needle aspiration of thyroid.

Nodules or abnormalities in the body are often detected by imaging examinations. However, it is not always possible to tell from these imaging tests whether a nodule is benign (non-cancerous) or cancerous.

The ultrasound guidance helps in the proper positioning of the needle in the target area. Hence, when there is a thyroid nodule and fine needle aspiration is performed, the needle is placed percutaneously in the nodule under ultrasound guidance. In, Medical coding, the CPT code for Fine Needle aspiration of thyroid is 10021 and 10022 (deleted in 2019). The difference is only about with or without guidance.

10021- Fine needle aspiration without guidance

10022 (deleted in 2019)- Fine needle aspiration with guidance

Their are new CPT codes for Fine Needle aspiration (FNA) in 2019. The new FNA CPT codes are bundled coded with imaging guidance. You can get all information here.

When to use Cpt Code 76536 thyroid ultrasound

Ultrasound imaging or sonography, involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound exams do not use x-rays. Because ultrasound images are captured in real-time, they can show the structure and movement of the body’s internal organs, as well as blood flowing through blood vessels.

Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions.

The real time ultrasound of thyroid is coded with CPT code 76536. Now, this code is a direct code. When the physician used real time ultrasound procedure to check the soft tissue of neck, thyroid, parotid region we use code 76536. This is the first and simple procedure to check any disorder in thyroid region. Therefore, before going to code CPT code for ultrasound guided biopsy of thyroid, many physicians perform real time ultrasound of thyroid.

Use of 26 and 25 modifier with Ultrasound and biopsy CPT codes

If the site of service is the hospital or the ASC, then use -26 modifier, this will show that the professional service was provided, which will help in the payment of the professional service. Payers will not reimburse physicians for the technical component in the hospital setting.

While reporting surgical procedure like biopsy on the same day as an office visit, add modifier -25 to the office visit code to indicate a “significant, separately identifiable evaluation and management service.” However, this modifier is not to be used routinely. The E/M service must be “…above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.”

Advantages of Fine needle aspiration Thyroid biopsy.

The results of Fine needle biopsy of the thyroid are close to 95% accurate for adequate biopsies.
Fine needle biopsy is the best method of obtaining tissue samples that can help diagnose whether a nodule is benign (non-cancerous) or malignant.
It is less painful procedure and the results are as accurate as when a tissue sample is removed surgically
Since Fine needle aspiration biopsies are less invasive procedure than open and closed surgical biopsies, hence the use of large incision and general anesthesia is not need for these procedures.

Hope, now you can easily code the procedure related to thyroid biopsy cpt code.If you like the article, do share it.