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Question: When I read an op note for a bone marrow procedure, I鈥檓 confused about the difference between aspiration and biopsy. How do I distinguish the procedures so I can assign the correct code?

Pennsylvania Subscriber

Answer: A provider will obtain a sample of bone marrow, most often from the patient鈥檚 pelvic bone, for a biopsy to determine the status of such conditions as blood cell diseases like leukopenia or thrombocytopenia, blood cancers like leukemias or lymphomas, or cancers that have metastasized into the bone marrow itself.

A bone marrow aspiration uses a fine gauge needle and withdraws a specimen of fluid and cells from the bone marrow, a spongy, semisolid tissue containing fluid and cellular material. A bone marrow biopsy uses a larger-bore hollow needle to withdraw a core of bone marrow tissue. The surgeon should indicate specifically whether the procedure is a bone marrow biopsy or a bone marrow aspiration. However, if the op note lacks that specific designation, you can use the procedure description to tell the difference.

To report the aspiration, you should use 38220 (Diagnostic bone marrow; aspiration(s)). For the biopsy, report 38221 (Diagnostic bone marrow; biopsy(ies)). And if the surgeon performs both procedures together at the same anatomic site, you should report 38222 (Diagnostic bone marrow; biopsy(ies) and aspiration(s)). Performing both procedures is common, because the specimens provide distinct diagnostic information for blood cell diseases such as leukopenia, thrombocytopenia, or blood cancers like leukemias or lymphomas.

Remember this (1): Per CPT^脪 instructions, you should not report both 38220 and 38221 for the same patient encounter when obtaining diagnostic bone material for pathological testing. However, the National Correct Coding Initiative (NCCI) Policy Manual explains that these two codes may be reported together 鈥溾��if the two procedures are performed without accompanying biopsy(ies) or aspiration(s) respectively on different iliac bones or sternum or at separate patient encounters.鈥� In such cases you will need to append a modifier to override the NCCI bundling edit.

So, if the surgeon performs multiple aspirations or biopsies at separate sites, such as the left and right sides of the pelvis, you can report each procedure and append a modifier to the second code. Depending on payer preference, you might use modifier 59 (Distinct procedural service) or modifier XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure) for Medicare or payers that follow Medicare guidelines.

Remember this (2): Very often, providers perform bone marrow aspirations under local anesthesia. When this happens, do not separately bill for the local anesthesia, as it is bundled within the aspiration service code.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC