Biopsy Coding in ICD-10-PCS


This course delves into the challenges of coding biopsy procedures within the ICD-10-PCS framework. It addresses the common coding dilemma of determining when to use the "X" value for "diagnostic" in cases of tissue biopsy. Furthermore, it provides a comprehensive explanation of the distinction between a diagnostic biopsy with specific objectives and a routine biopsy for the planned removal of tissue. The course also thoroughly covers the accurate application of root operations for different biopsy procedures, along with a review of official coding guidelines. To reinforce understanding, the course incorporates case scenarios into quizzes to assess the students' knowledge.

Included Lessons:

  • Characters in ICD-10-PCS Biopsy Codes
  • Root Operations
  • Coding Clinics
CEUs available for the following credentials:




Key Takeaways

Medical coders who complete this course will be equipped with several key takeaways. Some key takeaways include:

  • Challenge of Root Operations: Coding biopsies in ICD-10-PCS can be complex due to the various root operations available for these procedures.
  • Critical Role of Correct Root Operation: Selecting the correct root operation is crucial for accurate coding in ICD-10-PCS. The choice of root operation depends on the specific technique used by the surgeon during the procedure.
  • Root Operations for Biopsies: The root operations most commonly used for coding biopsies are excision, extraction, and drainage.
  • Interpreting Procedure Techniques: It can be difficult for coders to interpret the precise technique used in a procedure. Relying solely on the procedure's title is insufficient, necessitating a thorough reading of the entire operative report to accurately determine the ICD-10-PCS code.
  • Course Focus on Root Operation Differences: The course explores the differences between these root operations and provides examples of when to use each one.
  • Official ICD-10-PCS Coding Guidelines: The course references the official ICD-10-PCS coding guidelines related to biopsy procedures.
  • Coding Biopsy with Qualifiers: Biopsy procedures are coded using root operations Excision, Extraction, or Drainage along with the qualifier "Diagnostic." For instance, fine needle aspiration of the lung is coded as Drainage with the qualifier Diagnostic, while bone marrow biopsy is coded as Extraction with the qualifier Diagnostic.
  • Biopsy Followed by Definitive Treatment: If a diagnostic biopsy procedure is followed by a more definitive treatment, both the biopsy and the subsequent treatment should be coded. For example, if a breast biopsy is followed by a partial mastectomy at the same site, both procedures are coded.

Benefits of Taking this Course

  • Improved Coding Accuracy
  • Enhanced Understanding of Root Operations
  • Increased Confidence in Coding Biopsy Procedures
  • Better Compliance with Official Coding Guidelines
  • Ability to Differentiate Between Diagnostic Techniques
  • Skill in Coding Biopsy Followed by Definitive Treatment
  • Comprehensive Knowledge of ICD-10-PCS for Biopsies
  • Enhanced Career Opportunities for Medical Coders
  • Critical Skill Development for Healthcare Professionals
  • Effective Application of Excision, Extraction, and Drainage Codes


What is the primary challenge in coding biopsy procedures in ICD-10-PCS?

The primary challenge lies in selecting the correct root operation based on the surgical technique used, as this directly impacts accurate coding.

Why is it essential to read the entire operative report when coding biopsies?

Reading the entire operative report is crucial because it provides the necessary details to accurately determine the ICD-10-PCS code, especially when the technique is not evident from the procedure's title.

What are the key differences between the root operations Excision, Extraction, and Drainage for coding biopsies?

Each root operation has distinct criteria for its application in biopsy coding. Understanding these differences is essential to assign the correct code.

About our Medical Coding Courses

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a comprehensive online education platform for medical coders. With a catalog of over 200 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection approved by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPTE/M, ICD-10-CMICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatientoutpatientprofee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CMICD-10-PCSCPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams. 
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