Question

A 55-year-old female smoker presents with cough, hemoptysis, slurred speech and weight loss. chest x-ray done today demonstrates a large, unresectable right upper lobe mass, and brain scan is suspicious for metastasis. under fluoroscopic guidance in an outpatient facility, a percutaneous needle biopsy of the right lung lesion is performed for histopathology and tumor markers. a diagnosis of small cell carcinoma is made and chemoradiotherapy is planned. what cpt® and icd-10-cm codes are reported?

Answer 1

The correct answer is 32405-RT, 77002-26, C34.11.

When we look in the CPT index of Lung/Biopsy/Needle, it will direct us to the code 32405. Code 77002 is a suitable code for the fluoroscopic guidance as suggested by the parenthetical statement under code 32405 and by revising the code descriptor for 77002.  

Modifier 26 is added to signify the professional component. RT modifier is to suggest the right lung was where the biopsy was done. The diagnosis of the small cell carcinoma of the right lung is coded by C34.11.  

The signs and symptoms are not coded as there is no definitive diagnosis. The condition of brain metastasis is suspected but not confirmed so it would not be reported. The chemotherapy is strategic but not done so it would also be not reported.