How many codes should be assigned when a patient undergoes both a biopsy and subsequent removal of additional tissue?

How many codes should be assigned when a patient undergoes both a biopsy and subsequent removal of additional tissue?

• A. One
• B. Two
• C. Three
• D. Four

Answer: (B)

In this scenario, assigning two codes is appropriate because the procedures performed are distinct and each serves a specific purpose in the patient’s care. Biopsy typically involves taking a tissue sample for diagnostic purposes, while the subsequent removal of additional tissue usually represents further treatment based on the biopsy findings. When coding for these procedures, each one needs to be represented with its own code to accurately reflect the patient's clinical situation and the services rendered. This practice aligns with coding guidelines which dictate that each individual procedure should be captured separately if they are performed at the same time but are distinctly different in purpose. As a result, assigning two codes ensures that both the biopsy and the subsequent tissue removal are appropriately documented and charged.

In this scenario, assigning two codes is appropriate because the procedures performed are distinct and each serves a specific purpose in the patient’s care. Biopsy typically involves taking a tissue sample for diagnostic purposes, while the subsequent removal of additional tissue usually represents further treatment based on the biopsy findings.

When coding for these procedures, each one needs to be represented with its own code to accurately reflect the patient's clinical situation and the services rendered. This practice aligns with coding guidelines which dictate that each individual procedure should be captured separately if they are performed at the same time but are distinctly different in purpose. As a result, assigning two codes ensures that both the biopsy and the subsequent tissue removal are appropriately documented and charged.